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HomeMy WebLinkAbout2025-00041178 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100000 fl 0 01111 0 DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X0036 0152* u, 1 U2 14 4 1 U1 8 U2 U, 1 1_12 U, 1 U2 1 5 U1 1 U2 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW ' Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 11 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash 0 AMENDED YR 202512025-00041178 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 �l RT20 EB Elgin07:27 ® ❑ RELATED 0 Y ®N 06 27 2025 ❑AM ❑YES ®NO U1 —< _ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION m FT!MI N E S W S STATE EB EXIT RAMP COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR IR SLOW Cl)❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0 Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 NW 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 1 C) FOR DAMAGEDAREA(S) FRO TOWED U1 0 NAME(LAST,FIRST,M) /1 9 8 4 f tf Dodge Ram 1500(pickup) 2003 00-NONE ©, O 0DUE TO CRASH ® ❑ 13-UNDER CARRIAGE D) !. 2 FIRE ❑ ® < STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 ]$I U2 m M 2 4 ❑Y SYSTEM ❑UNK VEH. O ATCRASHD 0 99-OTHERWN 9 6II.T� `DistractionVatuc 9 ALGN = F CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST NTOONTACT 99 O7 _��:C{•f O ClrOyes.See Sidebar❑ U, 1 0 V Z Schaumburg IL 60193 B 1 0 2215633B IL 2025 REAR TELEPHONE IL D 1 D7HA16K63J638921 State Farm ❑Y I l N U2 m 5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Elgin Fire Same 3668603-SFP-13 1 r o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ® N 2 ou 0 DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMV 0 KCV 0 DV yr 12 _ 71 o 13-UNDER CARRIAGE 10 I c. 2 FIRE 0 ❑ U2 C c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP 3 0 ❑ SPDR O ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value U1 0 - POINT OF s-.;, 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRSTO CONTACT Y 6 I,_5 C•IO Ms See SidebarEH ❑ C CO F` REAR` co M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O ❑Y ❑N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X BAC HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 995 < RESP❑YDNDER❑N U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) n / / U2 r m Pj 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ®Y U2 Z Ni ® 2 1 61 /71 /025 07 27 ®AM in a Work Zone? ❑N DIRP co 1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 ,, v t 2 ❑ 19 20 61 1 71 /025 07 28 ®PM ®Construction >F R 3 0 ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME z J ❑AM 0 Maintenance U2 -a, oARREST NAME Cruz-Velazquez.Valerio 11-708 752161 61 /71 /025 07 36 Igi PM SLMT u 1 ❑ BI CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME• • 0 Utility p N 0 AM 25t 2 ❑ ARREST NAME Cruz-Velazquez.Valerio 11-501-A-2 75216 61 171 /025 08 30 0 PM ❑Unknown work zone type U1 n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 2 3 D 1549-Brown. Bryan 701 71 , 51 /025 09 00 0 PM ®N U2 REMEMBER TO USE BLACK INK,PRESS HARD,PRINT LEGIBLY AND COMPLETE ALL REQUIRED FIELDS! A Diagram and Narrative are required on all Type B crashes, LARGE TRUCK, BUS, OR HM VEHICLE even if units have been moved prior to officer's arrival. IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A Sp a?8trest ADDITIONAL UNITS FORMS. r r----T----, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< i- }__-_r_-__; INDICATE NORTH combination):or p0 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C _ } (example:shuttle or charter bus):or X 3. Is designed tocarry 15 or fewer passengers and operated a contract carrier O } A i es pa g pe NO To Sol* I I. } } transporting employees v in the course of ant(example:employee w transporter-usually a van type vehicle or passenger car):or c0 4. Is used or designated to transport between 9 and 15 passengers,including N } } } g Po passen rs,includi the driver, for direct compensation(example:large van used for specific purpose):or O L i..___a.....l t } } I 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m placarding(example:placards will be displayed on the vehicle). �g CARRIER NAME Z aTa` ADDRESS 'n C) CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate 0 Intrastate 0 1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other ; _Y_ _-1 _ USDOT NO. ILCC NO. m XI Source of above z . Were HAZMAT placards on vehicle? 0 Yes 0 No = If Yes,Name on placard O 4 digit UN NO. 1 digit Hazard class No. Xl Xl Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z own tank)? 0 Yes 0 No 0 Unknown Did HAZMAT Regulations violation contribute to the crash? r ❑ Yes 0 No 0 Unknown g D Did Carrier Safety Regulations MCS)violation contribute to the crash? A ❑ Yes II El Unknown C Was a driver/vehicle Examination Report Form completed? r HAZMAT ❑Yes 0 No ❑Unknown Out of Service ❑Yes ❑No 7 MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No C Z Form Number 0 m 71 IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2 TRAILER VIN 1 m co LOCAL USE ONLY TRAILER VIN 2 m 0 TRAILER WIDTH(S) 0-96" 97-102" >102' -n TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 o u 1 COLOR U_COLOR TRAILER LENGTH(S)1 ft. 2 ft. w White u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. _Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U_DUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO: DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE