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HomeMy WebLinkAbout2025-00045081 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 10110110011 0011 ail 1111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X463886160 u, 1 U21 1 1 1 U116 U2 1 U, 1 1_12 1 U, 1 U2 1 1 11 U1 1 U2 1 *P 0119* 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 El NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash El AMENDED YR 2025I 2025-00045081 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ® ❑ RELATED PRIVATE 0 Y ®N 07 12 2025 ❑AM ❑YES El NO U1 -< S RANDALL RD Elgin mo /day/yr 03:33 ®PM FLOW CONDITION m I0 ® O COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 cn !MI N E S W South St WITH VEHICLES INVLD ❑ STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑Y ® N PEDALCYCLIST®N ® FREE FLOW # LNS 0 (g:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 04 0 0 7 / yr 13-UNDER CARRIAGE ©,I �:: FIRE 0 (81 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 04 M M 2 SY n is-OTHER 5 ❑Y ®SNE M❑UNK VEH. AT CRASH IN n D 99-UNKNOWN 9 16•TOP 3 ,Distraction Value 9 ALGN 2 FPOF CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FRISTOONTACT 12 O7 ,ILS"1` S ClOM VEH See Sidebar El U1 1 0 Z ELGIN IL 60124 B 1 0 AR73370 IL 2026 REAR TELEPHONE IL D 0 1G6KD5RS2HU163691 Geico El ®N U2 I— i n EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Elgin Fire 99 9 Same 6165042646 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ® N 2 c p; DRIVER ❑ PARKED 0 DRIVERLESS ❑ FED ❑PEDAL 0 EWES ❑iiuv 0 NCv ❑Dv Yr 2 0 0 7 Nissan Pathfinder 2014 00-NONE 0. QNT!'-O DUE TO CRASH rg ❑ 2 x omo 13-UNDER CARRIAGE 10( I 2 FIRE 0 El U2 C c F 2 5 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X ❑Y NJ N DUNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 9 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 1 S .i. 4 C.OM VEH 0 ® U1 CO FIRST CONTACT 6 O7 ,�_Q,OS •If Yes,See Sidebar C ELGIN IL 60123 0 1 0 DP81264 IL 2025 FIRST Si)0 Z IL D 0 5N1AR2MM8EC699589 State Farm ❑Y ®N RDEF Xl EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 = Elgin Fire 99 9 Hernandez Velasquez.Jose. R. 3530883SFP13 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (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 0 Y U2 Z N 1 ® 11 1 71 ,21 )025 03 33 ®pm in a Work Zone? ®N DIRP co 1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP 0 AM U1 � 0 2 0 28 18 71 /21 /025 ❑PM El Construction * R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 o1 ® 11 1 ARREST NAME Galasso.Jeffrey. D. 11-601-Ax S150900164 71 ,21 /025 ❑PM SLMT o N • 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility AM t 2 El ARREST NAME 71 /21 /025 ❑❑PM El Unknown work zone type U1 45 2 2 3 ElOFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AR,' Workers present? ❑Y 45 1509-Wortman.Cassie 801 391-Jacobucci 81 , 31 /025 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 I 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-_--; I - INDICATE NORTH combination):or p0 i BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver (' - (example:shuttle or charter bus):or C L A I i 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 co N C L L____a____. \_ ) - I I 1 4. Is used or designated to transport between 9 and 15 passengers,including the driver. (I)c;o I hor ro er,rar � � � for direct compensation(example:large van used for specific purpose):or O 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). XI m fl C fl t 1 t 1 l 1 CARRIER NAME Z ADDRESS 0 D %- 1 i MEM w Ga CITY/STATE/ZIPg _ MOTOR CARR.ID 0 Interstate 0 Intrastate I I T I I I ❑ Not in Comm./Govt. 0 Not in Comm./Other I • USDOT NO. ILCC NO. rn Xl 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 v TRAILER WIDTH(S) 0-96" 97-102" >102' T TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 o u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Gray Gray 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 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE