HomeMy WebLinkAbout2025-00046516 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XO03894805
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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 El$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
0 AMENDED YR 2025I 2025-00046516 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
® ❑ RELATED ®Y ❑N 07 1$ 2025 ❑AM ❑YES ®NO U1
HIGGINS RD Elgin07:33
g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W N RANDALL RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR IR SLOW 1 (n
❑ Kane HIT&RUN ❑V ® 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!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 7 n
FOR DAMAGEDAREA(S) ROM TOWED U1 Q
NAME(LAST,FIRST,M) Esteban-Jimon.Juan mo
1 9 8 4 Chevrolet Traverse 2009 00-NONE 0' • 1z DUE TO CRASH ® ❑
_
13-UNDER CARRIAGE , FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O 'O DISTRACTED 0 0 U2 7 m
M 2 4 SY❑Y ®SNE❑UNK VEH. O AT CRAS IN H O 99-UNKNOWN 9 76•TOP 3 `Distraction Value 1 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF a ;i�S 4 COM VEH 0 1 O
F.
ELGIN I N I L 60123 0 1 0 FIRST CONTACT 12 7 ; _-5 *If Yes.See Sidebar U1
ZCG53056 IL 2025
TELEPHONE
IL D 1GNER23D19S176621 State farm ❑v ®N U2 I—
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same F2569827-SFP-13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER XI
Refused ❑Y ® N 2 c
p; DRIVER 0 PARKED 0 DRIVERLESS ❑ FED 0 PEDAL 0 EWES 0 NMV 0 NOV 0 DV
1 9 5 4 General Motor'�tlBary9 2017 00-NONE 1 t2 c,�2 FIRE DUE OCRASH rg ® U2 2 C
o Yr mo 13-UNDER CARRIAGE
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracl n Value 0
POINT OF 8 i 4 COM VEH ❑ ® U1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 5
FIRST CONTACT 6 O7 ,�=QIOS •(ryes See Sidebar C
Downers Grove IL 60516 0 1 0 HOMWRKS IL 2025aR 0
Z
IL B 7 1 G KS2G KCXH R380124 Safeco Insurance ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Bernstein.Cynthia Z5399013 BAC
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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
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#occs y
71
/ U1 1 D
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
u 1 ® 11 1 07,18 ,2025 07 33 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
0
2 ❑ 28 99 , , ❑PM• ❑Construction >F
R 3 ❑ 0 CITATIONS ISSUED El PENDING
PENDING SECTION CITATION NO. EMS ARRIVED TIME
❑AM ❑Maintenance U2
o1 El 11 1 ARREST NAME Esteban-Jimon.Juan 11-601 S1552000129 , r El PM SLMT
o N
0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility
0 AM
r 2 El ARREST NAME 07l 18 12025 08 20 0 PM 0 Unknown work zone type U1 5O
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 50
1552-Thompson.Ahmad Rashad 901 08 , 19,2025 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
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 truck trailer -<
i- }--_.r----; - combination):or
I iAbr ce , INDICATE NORTH C N 1 I >I I BY ARROW 2 Is used or designed to transport more than 15 g sp passengers including the driver C)
} Rd I I I } (example:shuttle or charter bus):or C
I I I 3. Is designed to carry 15 or fewer passengers and operated
�rated a contract carrier O
I- L----A � r - -
----. - }} } 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____� H - - } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver. C
- for direct compensation(example:large van used for specific purpose):or
rr - l. I I 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
rw�ezrzm
B placarding(example:placards will be displayed on the vehicle).
3
CARRIER NAME Z
ADDRESS 0
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C)
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
‘I. - --1 - USDOT NO. ILCC NO. m
XI
Source of above z
. If Yes,Name on placard 0
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
71
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
Green 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