HomeMy WebLinkAbout2025-00043669 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 0110110011 01000100100
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X00367 823
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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 0$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00043669 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED PRIVATE ' ' 0 N 07 06 2025 ❑AM ❑YES ®NO U1 -<
BOWES RD Elgin mo /day/yr 02:56 ®PM FLOW CONDITION Ill
02040!MI NOS W South Randall Rd COUNTY PROPERTY :IY ® N DOORING ❑y #OF MOTOR IDSLOW 1 (n
Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD IN STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
(i DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 Mies 0 NOV 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) 4 n
Y N
0 3 /
yr 13-UNDER CARRIAGE 1a.) 2 ' 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ ❑ U2 4 rn
M 2 4 SY❑Y ❑SNEM®UNK VEH. 9 AT CRASHD15-OTHER
9 99-UNKNOWN 9 76•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8_iL S I,.4 COM VEH 0 j$J 1 O
" �- SOUTH ELGIN I L 60177 0 1 0 FIRST CONTACT 12 r: _5 *I(Yes.See Sidebar U1
Z EW81381 IL 2025
TELEPHONE
IL D 4T1 BE30K95U071769 Kemper ❑v ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
David Moron. Marcos. R. 12RA000076168 2 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2
rg• g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEOAL 0 EWES 0 NMv 0 NOV 0 Dv
1 9 7 0 Jeep(after 191 ngler 2022 00-NONE ,1"j 12 -_, DUETO CRASH ❑ cg 2 x
o 13-UNDERCARRIAGE ta;l 2 FIRE ❑ ® U2 C
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M 2 4 SYSTEM IN 9 ENGAGED 9 15-OTHER 9 16.TOP 3 X
❑Y ❑N IN UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 iII S ..,_4 COM VEH ❑ ® Ut CO
FIRST CONTACT 6 Y__{_O ._5 •If Yes,See Sidebar
Z SOUTH ELGIN IL 60177 0 1 0 DG71674 IL 2026 i 0
D
IL D 1 C4HJXEG5NW149104 Geico ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
LALIBERTE.Gary. R. 6084545638 SAC 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)
2 3 09 /
U1 1 D
/ / 2 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 El 11 1 71112 125 02 56 ®PM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
0 2 0 03 18 , , ❑PM ❑Construction *
R 3 ❑ xi CITATIONS ISSUED El PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM ❑Maintenance U2
o1 ® 11 1 ARREST NAME Bastidas Angarita.Juan.C. 11-710-A 1560000027 , / El PM SLMT
o N •
❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
AM
r 2 El ARREST NAME 71 112 125 03 51 ®PM ❑Unknown work zone type U1 45
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 45
1560-Jones. Bennett 702 391-Jacobucci 81 , 12 ,25 09 00 ❑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 truckrtrailer -<
i- }---.r----; ( INDICATE NORTH combination):or —I
p1
I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- } (example:shuttle or charter bus):or
X
L A 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____.l '°""'R° 4. Isusedordesinatedtotrans rtbetween9and15 passengers,including C
} } for direct com nation exam I lar a van used for s �cifice ur o ):or the driver,
Pe ( P 9 Pe P Pose):or
L L--_-a-___.: - L i I L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). XI
Z-7,0
�t CARRIER NAME Z
1t. - ADDRESS O
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w n
Not To Scale 1 CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
i— ------1 - USDOT NO. ILCC NO. rn
XI
Source of above z
. • m
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z
own tank)? 0 Yes 0 No 0 Unknown
T.
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes ❑ 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
Xl
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' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Gold Black
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 1 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 0 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE