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HomeMy WebLinkAbout2025-00044193 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 6 Sheets 01111101111 I011011000 00I DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003886214 u, 2 U2 1 1 1 U116 u2 u, 1 U2 u, 1 U2 4 6 u, 1 U2 *P 0119* 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 ❑5501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash 0 AMENDED YR 2025I 2025-00044193 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n WEST BARTLETT RD El 02:05 ® ❑ RELATED ❑Y ®N 07 09 2025 ®AM YES ®NO U1 -< _ _ g PRIVATE mo !day!yr ❑PM FLOW CONDITION m FT N E S W RUZICH DR COUNTY PROPERTY ElY ® N DOORING ❑Y #OF MOTOR 0 SLOW Cl)❑ Cook HIT ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I CO AT RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Qg3 DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 C) 0 4 / yr © Pastor Perez. Rene Chevrolet Cruze 2018 00-NONE 11 . DUE TO CRASH VI �3-UNDER CARRIAGE to i 2 FIRE ❑ tz STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 m M 9 4 n is-OTHER ❑Y ®N SYSTEM ❑UNK VEH. AT CRASH D 99-UNKNOWN 9 16•TOP 3 ,Distraction Value ALGN = • T. CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $,_iL 6 I, 4 COM VEH 0 Ea 1 O F. FIRST CONTACT 1 7 ;-_;__5 Z Carol Stream IL 60188 0 1 0 FM 11994 IL 2026 " *Yves.See Sidebar U1 8 TELEPHONE IL D 1 G 1 BESSMXJ7241136 Direct Auto ❑Y ®N U2 ni 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same PAIL001206095 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ® N 3 2 rg- ❑ DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMV 0 Ncv 0 DV yr ,2 - C o 13-UNDER CARRIAGE 10 I 2 FIRE ❑ ❑ U2 C c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP 3 ❑ ❑ SPDR O ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistrac) n Value U1 9 - POINT OF s-.;, 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT Y�='+:=6 COM•I sVEH See •Sidebar❑ ❑ C CO F` pEAR` co M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O ❑Y ❑N RDEF73 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 995 < RESP❑YD❑N NDER U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) n / / U2 r m Pj / 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 43 3 07,09 ,2025 02 05 ®❑pM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 2 0 08 20 ! ! ❑PM• ❑Construction * t Z3 0 1!>I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 -a, ARREST NAME Pastor Perez. Rene 11-709-A 752173 , , ❑PM o u 1 0 �!CITATIONS ISSUED ❑PENDING TIME • ❑Utility SLMT o N SECTION CITATION NO. ROAD CLEARANCE AM 45 t 2 El ARREST NAME Pastor Perez. Rene 6-303-A 752175 ! ! 0 pM ❑Unknown work zone type U1 n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑Y 1559-Dav'c los.Yoana 401 331-Ziegler , , ❑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 Notfi I I 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__. 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y I I } } } for direct compensation(example::large van used for speific purpoe):or the driver. L L____ -___. J Ill t i i. 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires .D placarding(example:placards will be displayed on the vehicle). O m jllfoit?BfrUott?R dt —Unit 1 _ XI I- I- -:- '.. it. , L i. i. ..... ..... CARRIER NAME —I ADDRESS w R n CITY/STATE/ZIPg 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 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_COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Black 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_TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO:DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE