HomeMy WebLinkAbout2025-00042024 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets _ 01111101111 0110110000 l0I 10100
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003813146.
u, 9 U2 1 1 1 U1 2 U2 U199 u2 U,99 U2 1 9 9 U1 1 U221 *P 0119*
INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500
El NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00042024 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 mABBOTT DR Elgin
® ❑ RELATED ❑Y ®N 07 01 2025 ®AM ❑YES El NO U1 -<
PRIVATE mo /day/yr 05:28 ❑PM FLOW CONDITION m
_
g6OCIO!MI NOS W Adeline Dr COUNTY PROPERTY ElY ® N DOORING El #OF MOTOR NISLOW 15 u)
Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD El STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
18:DRIVER (] PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
r /
FOR DAMAGEDAREA(S) FRONir�TOWED U1 Q
NAME(LAST,FIRST.M) Unknown.O. mo Chevrolet Silverado 00-NONE 11_' Qz ,a:/DUE TO CRASH ❑
13-UNDER CARRIAGE 10 i , 2 FIRE ❑ IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ga U2 2 m
SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3
9 9 ❑Y 0 N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _iL a ii,4 COM VEH ❑ Ea
~ 0 9 0 FIRST CONTACT 1 7.
;mai -5 *lI Yes.See Sidebar Ut 0
2 Z ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1)
Unknown ❑Y ❑N U2 I—
.9 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same Unknown 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
r D Y°N❑l N 0
❑ DRIVER N. PARKED 0 DRIVERLESS 0 PEO 0 PEOAL 0 EWES 0 r My 0 KCV 0 DV
yr Chevrolet Equinox 2014 00-NONE 1("j 12.._-1 DUE TO CRASH 0 ® 1 X
o ,, 13-UNDER CARRIAGE 10'I c. 2 FIRE ❑ ® U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP 3 ❑ ® SPDR n
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value U1 9 -
POINT OF s ) -4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR • COM VEH D ® CO
F,,, FIRST CONTACT 7 O7 ,�=QI._5 •Irves,See Sidebar
EB39212 IL 2025 aR 0 Si)
•
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
2GNALBEK4E6206218 Progressive ®V ❑N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Flores. Richard 988095211 BAC
• $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 18 1 07,01 r2025 05 28 ®❑pm in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 0 20 28
N 3 0 0 CITATIONS ISSUED 0 PENDING + ) • ❑PM ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM ❑Maintenance U2
-a, ARREST NAME / / ❑PM '
o N 1 ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT
30
r 2 0 ARREST NAME AM
7 1 r ❑❑PM ❑Unknown work zone type U1
n •
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 - ❑AM Workers present? ❑Y 30
1556-Sanchez.Jimena 501 r { ❑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
ADDITIONAL UNITS FORMS.
r ----r••--, , ; 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 .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} Not 7b Scale I } (example:shuttle or charter bus):or 0
3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
. - . transporting employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
L L.___a__... _ _____" 4. Is used ordesi natedtotrans rtbetween9and15passengers,indudingthedrrver, C
J� Yz t F •
for direct compensation(example:large van used for speific purose):or
L ..I... . - t i i I 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
M
Aee dno. m
placarding(example:placards will be displayed on the vehicle). XI
—I
CARRIER NAME Z
ADDRESS 0
rxsr®orerx D
CITY/STATE/ZIP 00
MOTOR CARR.ID 0 Interstate ❑ Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
-----------1 - USDOT NO. ILCC NO. rn
73
Source of above Z
—I
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?
❑ Yes II No El Unknown A
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
Xl
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
White Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 9 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE