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HomeMy WebLinkAbout2025-00046323 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 6 Sheets 01111101111 I011011000 01 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003694718. u, 2 U21 2 4 1 U1 2 U2 1 U1 1 U2 1 U1 1 U2 1 5 15 U, 1 U2 1 *P 0119 INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW ' Elgin Police Department ONE PERSON'S ❑5501-51.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) El B Injury and/or Tow Due To Crash El AMENDED YR 2025I 2025-00046323 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 -n ® ❑ RELATED ®Y 0 N 07 17 2025 ❑AM ❑YES ®NO U1 -< ERIE ST Elgin11:11 _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m FTlMI N E S W S MCLEAN BLVD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n ❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLESOT, INVLD ❑ STOPPED U2 —I El 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 EDUCE 0 uuv 0 ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 C) T TOWED U1 Q NAME(LAST,FIRST,M) mo yr Miranda Garcia. Ramiro Chevrolet Express 2005 00-NONE „. OUETOCRASH ® ❑ Q 13-UNDER CARRIAGE i : 2 FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 4 <Tl< 19 M 2 4 ❑Y ❑SNEM® 15-OTHER UNK VEH. 9 AT CRASHD 9 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ i�S �i COM VEH 0 Ea 1 0 ELGIN I L 60123 B 1 0 FIRST CONTACT 11 7_: __5 *Ilsees.See Sidebar U1 Z 3416518B IL 2026 REAR TELEPHONE IL Other 0 1 GCGG29V351156247 Unknown ❑Y ❑N U2 m .5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Piedra. Rosalinda Unknown 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER 2 ou m E{ DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 toy 0 RGV 0 Dv !2 0 0 9 Jeep(after 19681�rokee 2019 00-NONE al z j.-_, DUE TO CRASH 0 ❑ 2 x 0 13-UNDER CARRIAGE 9 I ©). 2 FIRE 0 ® U2 C c M 2 5SYSTEM IN 9 ENGAGED 9 15-OTHER 9;16•TOP 3 X 0 Y ❑N ®UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value 0 i N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF FIRST CONTACT 1 O 8 7i1 B 4 COM VEH ❑ ® .5 •If Yes.See Sidebar U1 CO = BARTLETT IL 60103 B 1 0 DH91121 IL 2026 REARO IL D 0 1 C4PJ LCB3KD392302 State Farm ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Majerski. MARIUSZ 1947347-SFP-13 SAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)({ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) U2 996 r m / / ##occs y Pj / / UI 1 D / / 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z u N 1 ® 11 1 07,17 l2025 11 11 ®PM AM in a Work Zone? ®N DIRP D 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 2 0 2 19 07,17 /2025 11 11 ®PM 0 Construction * R O 0 xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 3 ❑AM 0 Maintenance U2 -a, ARREST NAME Miranda Garcia. Ramiro 11-901-A 752206 07/17/2025 11 15 ®PM SLMT o U1 ® 11 1 CITATIONS ISSUED 0 PENDINGTIME • ❑Utility o NSECTION CITATION NO. ROADCLEARANCE 0 AM 35 t 2 El ARREST NAME Miranda Garcia. Ramiro 11-401-A 752203 , / PM 0 Unknown work zone type U1 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 35 494-Kirsh. Katherine 602 402-Free 08 , 14,2025 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 } } -I- _, I 0 - } combination): r more than pound (example:truck or truckrtrarler 1. Has a weight rating10 000 5 i -< �� INDICATE NORTH Ilon)o P3 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 I I.- } 3. Is designed to carry 15 or fewer passengers and operated a contract carrier 0 } transporting employees in the course of their employment(example:employee X transporter-usually a van type vehicle or passenger car):or w __ __ I 4. Is used or designated to transport between 9 and 15 passengers,including C } } } g po passen rs,includi the driver, x for direct compensation(example:large van used for specific purpose):or L L____a____I J i'i- 9. Erreear _ l. I I 5. Is any vehicle used to transport anyhazardous material(HAZMAT)thatrequires m �— placarding(example:placards will be isplayed on the vehicle). 40 . 2# —� '� CARRIER NAME Z _ ADDRESS 0 r r T 1 1 11 r CITY/STATE/ZIP w Not To Scale - i. i. i. i. MOTOR CARR.ID 0 Interstate 0 Intrastate I I T I 0 Not in Comm./Govt. 0 Not in Comm./Other � "Y""4 USDOT NO. ILCC NO. m XI Source of above z . • m 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 White 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