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HomeMy WebLinkAbout2025-00042172 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I011011000 0 IIIIIIII DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003674201 u, 1 U21 1 1 1 U1 4 U2 1 U, 1 U2 1 U, 1 U2 1 1 11 U1 1 U211 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El5501-51.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 2025512025-00042172 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ® ❑ RELATED PRIVATE ❑Y ®N 07 01 2025 ❑AM YES ®NO U1 -< DUNDEE AVE Elgin mo /day/yr 02:56 ®PM FLOW CONDITION 111 COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 cn ®50 ®!MI N E p W Plum Ct WITH VEHICLES INVLD 0 STOPPED U2 —I El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑Y ® N PEDALCYCLIST®N ® FREE FLOW # LNS 0 18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PEO 0 PEOAL 0 EDUES 0 ION 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0 FTtO 1T�TOWED U1 NAME(LAST,FIRST,M) Baez-Gonzalez. Mahon.G. mo yr Kia Motors Co tima 2012 00-NONE ©1 • 0 >,/OUETOCRASH ❑ 13-UNDER CARRIAGE DI E 10 1 2 FIRE 0 tE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 4 rn M 2 SY4 ❑Y ®SNE❑UNK VEH. 0 AT CRASM IN H 0 99-UNKNOWN 9 16•TOP 3 `Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s ;il a _4 5 •u Yes.See Sidebar U1 COM VEH 0 Ea 1 0 F. FIRST CONTACT 12 7,. ,_ Z GILBERTS IL 60136 0 1 0 EV18289 IL 2025 TELEPHONE IL D 5XXG R4A69CG059789 American Alliance ❑Y Il N U2 19 , m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same I LAA0992863 01 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER en Refused 0 Y ® N 2 0 x DRIVER ❑ PARKED 0 DRIVERLESS ❑ FED 0 PEDAL 0 EWES ❑r uv 0 NOV ❑DV CIRCLE NUMBER(S) U1 !1 9 yf 7 Honda Odyssey 2015 00-NONE 11 j 12..-_1 DUE TO CRASH ❑ 2 x 0 13-UNDER CARRIAGE 10'( 2 FIRE 0 El U2 C c M 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X 0 Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN `0istraellon Value 0 POINT OF 5 S i 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 6 O7 a 7W2 0 COM VEH ❑ ® U1 W 5 •If Yes See Sidebar C Z Algonquin IL 60102 0 1 0 Z185921 IL 2025aR 0 Si)Z IL D SFNRL5H69FB113069 State Farm ❑Y ®N RDEF71 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 = May.Jennifer 2454033-SFP-13 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) U2 996 r m ##occs y 71 / ,, U1 1 D 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 11 1 07,01 ,2025 02 56 ®PM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 o" 2 28 99 + / ❑PM• ❑Construction * R 1 3 0 $I CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM 0 Maintenance U2 a ® 11 1 ARREST NAME Baez-Gonzalez. Milthon.G. 11-601 S1552000118 , r El PM SLMT o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility 0 AM t 2 0 ARREST NAME 07l 01 12025 02 58 ®PM El Unknown work zone type U1 3O 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 30 1552-Thompson.Ahmad Rashad 201 08 , 19,2025 01 30 ®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: Z1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<} }---_r__--; combination):or INDICATE NORTH BY ARROW2 Is used or designed to transport more than 15 passengers including the drivern1111. (example:shuttle or charter bus):or3. Isdesgnedtocar 15orfewer ssen ersando rated a contract career O -----A----i } } } transporting employees in the course their employment(example:employee transporter-usually a van type vehicle or passenger car):or w L L.___a__ 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or O L hA t i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D w,�acr placarding(example:placards will be displayed on the vehicle). XI CARRIER NAME Z / ADDRESS w N - Not To Scale J i7 CITY/STATE/ZIP . , MOTOR CARR.ID El Interstate El Intrastate . 0 , Drndeetaue 0 Not in Comm./Govt. 0 Not in Comm./Other O i— --- '-1 - USDOT NO. ILCC NO. rn XI 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 ElUnknown 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' T TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z White White u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO: _ . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO: DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE