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HomeMy WebLinkAbout2025-00044981 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I011011000 00 I II I*IIIIIIIIIII DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X463886168 u, 9 U21 2 4 2 u, 3 U2 1 u,99 1_12 1 u, 1 U2 1 4 15 u, 1 U2 1 *P 0119 INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S ❑$501-51.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) (8:1B Injury and for Tow Due To Crash El AMENDED YR 2025I 2025-00044981 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 16 mN LIBERTY ST Elgin 01:44 ® ❑ RELATED I81 Y 0 N 07 12 2025 ®AM ❑YES ®NO U1 -< g PRIVATE mo !day!yr ❑PM FLOW CONDITION m FTlMI N E S W LINCOLN AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 u) ❑ Kane HIT&RUN IZ V ❑ N WITH VEHICLES INVLD ❑ STOPPED U2 -I CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EDUCE 0 uuv 0!CV ❑ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n FOR DAMAGEDAREA(S) FROPtf TOWED U1 Q Unknown.O. ! ! Mitsubishi Outlander 2019 00-NONE ©, 12 , DUE TO CRASH ® ❑ NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE I ! FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) OO. 2 U2 2 < 9 9 SYSTEM IN O ENGAGED O 15-OTHER 9 16-TOP 3 DISTRACTED 0 ]$I = ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6, i�6 Ii COM VEH 0 0 1 0 REAR Z 0 1 0 B P81332 I L FIRST CONTACT 11 7_; __5 *If Yes.See Sidebar U1 TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1) JA4AR3AU8KU031306 Unknown ❑Y 0 N U2 Ill , m B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR co Velazquez Bahena. Inoscencia Unknown 2 m `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 99 0 m E{ DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑ uv 0 e v ❑Dv /1 9 5 7 Honda CRV 2013 00-NONE 13-UNDER CARRIAGE ,� t2 DUE TO CRASH 0❑ ® U2 2 0 FIRE c F 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X 0 Y El N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 9 POINT OF 6 i1 4 COM VEH 0 ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR A 6 L - FIRST CONTACT 1 7� -5 •If Yes,See Sidebar HOFFMAN ESTATES IL 60192 0 1 0 AN41546 IL 2025 I0 IL 5J6RM3H71DL037524 State Farm ❑Y ®N RDEF71 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same 0979695-SFP-13 BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused E Y°®N 3 u1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 1 07,12 /2025 01 44 ®❑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 Eri 2 0 23 28 N 3 0 CITATIONS ISSUED ID PENDING / 1 ❑PM El Construction >E SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 -a, ARREST NAME / / El PM ' oN ® 11 1 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT r 2 0 ARREST NAMEAM T ( / PM 0 Unknown work zone type 30 U1 n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ ❑AM Workers present? 0 Y 30 1559-DavE los.Yoana 201 331-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 Not TO Scale I I ADDITIONAL UNITS FORMS. r -- r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z IA I 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer - i- }--__r-_--; d I } combination):or -I INDICATE NORTH 1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C I (example:shuttle or charter bus):or 0 X l Ne 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 transporter-usually a van type vehicle or passenger car):or w ' . 4. Is used or desi nated to trans rt between 9 and 15 ge ng rCjt L -----------I. I �. - } } } g po passen rs,includi [he driver, I ^;53 for direct compensation(example:large van used for specific purpose):or O L L____a____� J L i L i. L 5. Is any vehicle used to transport any hazardous material(HAZMAT) •u placarding(example:placards will be displayed on the vehicle). m 0 I L1nmrr Ave.i - -- CARRIER NAME Z 1 I ADDRESS 0 CITY/STATE/ZIP 0 g , I r - MOTOR CARR.ID 0 Interstate 0 Intrastate 5 O I i 1 ❑ Not in Comm./Govt. Not in Comm./Other 0 :-----H--4. 1 : : : : USDOT NO. ILCC NO. < m [N.mibertyrstd , , , Xl Source of above z . 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 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 VIM 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 Black Silver u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. _Redmons/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO: DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE