HomeMy WebLinkAbout2025-00043613 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 10110110011 010001011110
DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003877B24
u, 9 U2 1 1 1 U1 99 U2 U199 1_12 U,99 U2 1 1 9 U1 1 U221 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00043613 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 71
309 KATHLEEN DR Elgin05:20
® ❑ RELATED ❑Y ®N 07 06 2025 ®AM El YES El NO U1 -<
_ g PRIVATE mo /day/yr ID PM FLOW CONDITION MCOUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 U)
❑ FT!MI N E S W Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD ❑ STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER I] PARKED D DRIVERLESS 0 PED ❑PEDAL 0 EDUCE 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
! ! FOR DAMAGEDAREA(S) FRONT :TOWED U1 Q
Unknown.0. Jeep(after 1968)Ind Cherokee 00-NONE „ , DUE TO CRASH ❑ EN
NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 101 12! 2 FIRE 0
IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTEDU2 2 <
9 9 SYSTEM IN 9 ENGAGED 9 15-OTHER 9 16.TOP 3 0 _
❑Y IDN ®UNK VEH. AT CRASH ®-UNKNOWN `Distraction Value ALGN
s 4 COM VEH 0 Ea r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _I[S !i,_ 1 0
I- 0 9 0 FIRST CONTACT 99 7_; _5 *II Yes.See Sidebar U1
REAR
2 Z ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1)
Unknown ❑Y ❑N U2 I—
Si EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same Unknown 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER •
RESPONDER D
Refused ❑Y ® N 99 0
0 DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uv 0 NOV 0 Dv
yr 10;j 12 c, 2 FIRE ID El U2 1 C
o 13-UNDER CARRIAGE
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN 0 ENGAGED 0 15-OTHER 911,6•TOP3 0 ® SPDR n
❑Y ❑N DUNK VEH. AT CRASH 99-UNKNOWN `Oistraci n Value 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF O Ij- 4 COM VEH D ® U1 CO
F,,, FIRST CONTACT 7 O7 7_L"-i�_�OS •If Yes.See Sidebar C
N/A " 4 f/)
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
1 G11A5SL4EF293954 None ❑Y ❑N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
Perez Hernandez.Jose. F. None BAG • $
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)((A.DDRESS)(TELEPHONE) (EMS) (HOSPITAL)
DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 18 9 07,06 /2025 08 18 ®❑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
2 ❑ 18 99
N 1 3 ❑ ❑CITATIONS ISSUED 0 PENDING + ! • ❑PM• ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
-a, ARREST NAME / / ID PM '
o N 1 ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT
30
T 2 ❑ 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 ❑ - ❑AM Workers present? ❑Y 30
1545-VanEycke. Brier 602 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•..-, , Krumnvv A CMV is defined as any motor vehicle used to transport passengers or property and: Z' }-- _r_ --; ® 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -1
- _ combination):or —1'7m1CAtriaa } INDICATE NORTH p1
Not To Scale I NM I I I BY ARROW C
2 Is used or designed to transport more than 15 passengers including the driver
- } (example:shuttle or charter bus):or
3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
- }----A---
•. k - } } } transporting employees in the course of their employment(example:employee
1 1 1 w (`••r+•`„ " ,. .'i transporter-usually a van type vehicle or passenger car):or w
L L.___a____� a:a::...,77 .7,,, .«»< _ } } } •4. Is used or designated to transport between 9 and 1passengers,includingthedriver, C
... .fir�t for direct compensation(example:large van used fors specific purose):or
L L____a____. .,ea _ t i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). ;p
CARRIER NAME Z
r 6)
g ueoraeo: ADDRESS D
rn
s' ''.'r CITY/STATE/ZIP n
MOTOR CARR.ID ❑ Interstate ❑ Intrastate
1 I r 1 ❑ Not in Comm./GaA. Not in Comm./Other0
;____Y____ USDOT NO. ILCC NO. rn
XI
Source of above z
. Form Number
m
Xl
IDOT PERMIT NO. WIDELOAD'; 0 Yes 0 No 2
TRAILER VIN 1 m
to
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
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: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE