HomeMy WebLinkAbout2025-00043471 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 11111M UHI
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DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X00387958/
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 3
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 2025I 2025-00043471 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 :1
® ❑ RELATED PRIVATE ❑Y ®N 07 05 2025 ❑AM ®YES 0 NO U1 -<
RT20 WB Elgin mo /day/yr 06:46 ®PM FLOW CONDITION M
•®10Q /MI N CIS W South State St COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR IR SLOW Cl)
Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0
DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
0 7 /
yr 13-UNDER CARRIAGE 16 1 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® ❑ U2 rn
M 2 SYTM 4 ❑Y ®S NE❑UNK VEH. 0 AT CRASH 99-UUNKNOWN THER9 t6•TOP 3 *Distraction Value 7 ALGN
-
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6, ii_6 1,.4 COM VEH 0 El 1 0
~ SOUTH ELGIN N I L 60177 0 1 0 FIRST CONTACT 12 7 ; _5 *II Yes.See Sidebar U1
ZEC94565 IL 2025 REAR
TELEPHONE
IL D 1 D4HB58D05F523320 Progressive ❑Y I l N U2 m
5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
03
Same 981070685 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 NMy 0 Ncv 0 DV
yr 12 _ 71
o 13-UNDER CARRIAGE 10.i t, 2 FIRE ❑ ❑ U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 ❑ ❑ SPDR 0
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value U1 0 -
POINT OF s-.;, 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRSTO CONTACT Y 6 I,_
CIOMs gee SidebarH
0
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 =
BAC
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
RESPNDER❑YD❑N U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(A.DDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0
1 3 02 / F 2 5 0 1 0
I11
/ / #OCCS >
77
/ / UI 2 D
/ / 0
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ®Y U2 Z
N 1 ® 24 5 I.D.O.T Guardrail 07/05 /2025 06 46 ®PM in a Work Zone? ❑N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
v t 2 0 2300 S DIRKSEN PKWY Springfield) 62764 20 99 / / ❑AM ®Construction *
R 3 ❑ $I CITATIONS ISSUED El PENDING SECTION CITATION NO. EMS ARRIVED TIME
❑AM ❑Maintenance U2
-a, ARREST NAME Verzosa. Brandon. R. 11-709-A S1563-000021 / / El PM SLMT
o u 1 ❑ 0 CITATIONS ISSUED PENDING Utility
o N El AM SECTION CITATION NO. ROAD CLEARANCE TIME • ❑
t 2 El ARREST NAME 07/05 /2025 07 26 ®PM 0 Unknown work zone type U1 45
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑y
❑AM Workers present?
2 3 ❑
1563-Rodriguez.Carlos 701 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: 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
- } (example:shuttle or charter bus):or
, 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
I- -----A---.-:
I } } } transporting employees in the course of their employment(example:employee
rter-
y a van type
CO
L L.___a__ 4alsuosedordestlnatedto transport betweeicle or n9 and r15r) ssen rs,indudingthedrrver,
} } } for direct compensation(examp large van used for specific purpose):or N
Not To Scale i •OD
L L_._-a..... i t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
rn
"m:or aa«nm+rmiai placarding(example:placards will be displayed on the vehicle). Xi
®' --
it* CARRIER NAME —IZ
aWnwew
a, ao ADDRESS O
w
0
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
. —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. XI
XI
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 ❑ 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
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_COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Silver
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Adieu/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U_TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO:
DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE