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HomeMy WebLinkAbout2025-00047454 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I0110110000111110111011 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003696436 u, 1 U21 4 4 1 U116 U2 1 U, 1 U2 1 U, 1 U2 2 1 11 u, 1 U211 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 11 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash 0 AMENDED YR 2025I 2025-00047454 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn ® ❑ RELATED PRIVATE ®Y 0 N 07 22 2025 12,-AM ❑YES ®NO U1 -< RT20 EB 1 LAVOIE AVE Elgin mo /day/yr 06:40 ®PM FLOW CONDITION m ®20 ®!MI N Q s w Rt ZO)Lavoie Ave COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 2 Cl) Cook HIT&RUN ❑Y ® N WITH VEHICLESOT, INVLD ❑ STOPPED U2 —I 0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 NW 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 1 C) FOR DAMAGEDAREA(S) FROf T TOWED U1 0Amez Amezquita Canales. Daniel 0 5 / yr 13-UNDER CARRIAGE ©,I 0,,:O FIRE ❑ al STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® 0 U2 1 r<rl M 2 SY4 ❑Y ®SNE❑UNK VEH. O AT CRAS IN H O 99-UNKNOWN 916•TOP 3 `Distraction Value 6 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s it S �i COM VEH 0 El 4 n 4 I— FIRST CONTACT 11 7__ --_;__5 *IIYes.See Sidebar U1 0 V Z Streamwood IL 60107 0 1 0 Z219204 IL 2026 REAR TELEPHONE IL D 2B3CA3CVOAH2O7926 American Freedom Insuranc ❑v ®N U2 13 , m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Canales Trejo.Angelica 12245431400 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 XI x DRIVER 0 PARKED 0 DRIVERLESS ❑ PED 0 PEDAL 0 EWES 0 1 9 9 O Chevrolet Silverado 2006 00-NONE 10 I 12 c,�2 FIRE DUE D CRASH 0 ® U2 2 C o - 13-UNDER CARRIAGE II M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•Top 3 X ❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN O *Oistracton Value 0 POINT OF S I jl 4 COM VEH D ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6 FIRST CONTACT 5 7 -_,SOS •If Yes.See Sidebar Z Schaumburg IL 60194 0 1 0 4075530B IL 2026 I 0 Si)c D IL D 1GCEC19V56Z184227 State Farm ❑Y ®N RDEF ZI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 8 x Same 0575298sfp13 BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(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 07,22 i2025 06 40 ®AM 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 C) o" 2 ❑ 28 99 + ) ❑PM• ®Construction * 3 R 3 ❑ $ I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 oD ® 11 1 ARREST NAME Amezquita Canales. Daniel 11-601-Ax 1545-348 / ! El PM SLMT o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility 0 AM t 2 ❑ ARREST NAME 071 22 12025 06 45 ®PM ❑Unknown work zone type U1 3O 2 2 3 El El ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? D Y 30 1545-VanEycke. Brier 401 08 ,26/2025 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 r - combination): r more than pound (example:truck or truck/trailer 1. Has a weight rating10 000 5 -< INDICATE NORTH o P3 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C r r r (example:shuttle or charter bus):or 0 Not TO Scat.. 3. Is designed to carry15 or fewer g passengers and operated by a contract carrier I O I- I- -A---•i - } ,} } 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 C} } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or O ' L.__-a..... t i i t 5. Is any vehicle used to transport an hazardous material(HAZMAT)that requires -0- __ ___*iI.-t9 --. placarding(example:placards will be displayed on the vehicle). XI +, ') CARRIER NAME Z O/' \ ADDRESS V) C) CITY/STATE/ZIP g tiger iltw - t. MOTOR CARR.ID 0 Interstate 0 Intrastate 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 . MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No 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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO: DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE