HomeMy WebLinkAbout2025-00043919 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003680470`
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT) El B Injury and/or Tow Due To Crash
El AMENDED
YR 2025I 2025-00043919 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
FORD AVE Elgin 06:30
® ❑ RELATED ®Y 0 N 07 07 2025 ❑AM ❑YES ®NO U1 -<
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION ITI
FT!MI N E S W HIAWATHA DR COUNTY PROPERTY ❑Y 21N DOORING Ely #OF MOTOR 0 SLOW 1 cn
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0 Icy ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) y N O C)
FOR DAMAGEDAREA(S) FRO!T�TOWED U1 Q
Hernandez.Jicela 0 1 /
yr 13-UNDER CARRIAGE } FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O 2 DISTRACTED 0 0 U2 O 171
F 2 3 SYTM❑Y ®S NE❑UNK VEH. O AT CRASH 0 15-99-UUNKNOWN THER9 16•TOP 3 *Distraction Value ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF T :i1 4 COM VEH 0 j$J 1 0
~ ELGIN I L 60120 0 1 0 FIRST CONTACT 12 7_; __5 *lives.See Sidebar U1
Z EN26722 IL 2026 Ismi
TELEPHONE
IL D 0 19UUB5F47MA007502 PROGRESSIVE ❑Y ®N U2 I'
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Cruz.Jonathan 982325821 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 eu
x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0!My 0 Ncv 0 DV
Yr
/2 0 0 0 Ford Focus 2010 00-NONE O1 Qj O DUE TO CRASH ❑ 2
0 13-UNDER CARRIAGE f.` FIRE ❑ ® U2 C
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracuon Value 9
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF si S i.�.,_4 COM VEH D ® U1 CO
FIRST CONTACT 1 7 _, _5 C.
If Yes.See Sidebar C
ELGIN IL 60120 0 1 0 DV91493 IL 2025 I9 N
IL D 0 1 FAH P3FN 1 AW171248 NATIONAL GENERAL ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 2019027673 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 6 10 / F 12 3 0 1 0
m
/ / #OCCS D
71
/ / UI 2 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 El 11 1 07/07 /2025 06 30 ®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 ❑ 23 28 / / ❑PM ❑Construction >E
4
R 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM ❑Maintenance U2
o1 ® 11 1 ARREST NAME Hernandez.Jicela 11-1204-B S1519-000367 / / El PM SLMT
o N •
❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility
0 AM
T 2 El ARREST NAME 07/07 /2025 07 05 ®PM El Unknown work zone type U1 25
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 25
1519-Bae2 a.Guadalupe 201 08 /05/2025 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 -<
` ` --1 -' 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
X
3. Is designed to carry15 or fewer passengers and operated a contract carrier 0
} A i
} } I- transporting employee �In the course of their employment(example:employee 73
4Ija .
FeruvAw • transporter-usually a van type vehicle or passenger car):or CO
L L.___a__ 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including C} } for direct compensation(example:large van used for specificpurpose):or [he driver,
' Pe ( P 9 Pe or o
i UNIT
L L----a--- t -_e ',,— - t i 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).
. . . . I lir 2#
0 CARRIER NAME Z
Nuwenraaar _ ADDRESS 0
V)Not To Scale j
CITY/STATE/ZIP C)0
MOTOR CARR.ID 0 Interstate El Intrastate
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
; _Y_ _ 4. - USDOT NO. ILCC NO. m
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? 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' -n
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
White Red
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
Arties/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE