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HomeMy WebLinkAbout2025-00048830 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I011011001 0 111 Ol II 110 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003902301 u, 1 U21 3 1 1 U110 U2 1 U, 1 1_12 1 U, 1 U2 1 1 10 u, 2 U2 4 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q 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 51,500 ❑NOT ON SCENE(DESK REPORT) El AMENDED ElB Injury and for Tow Due To Crash YR 202512025-00048830 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I ® ❑ RELATED ' ' 0 N 07 28 2025 ❑AM ❑YES ®NO U1 -< S LIBERTY ST Elgin02:39 _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m FT!MI N E S W VILLA ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 2 fA ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I lgi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N 51 FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EDUCE 0 NIAV 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n FOR DAMAGEDAREA(S) FRON T TOWED U1tzl Q NAME(LAST,FIRST,M) COLLINS.SATI NO mo /1 9 7 1 Ford Escape 2022 00-NONE ©, 12 , DUE TO CRASH ❑ 13-UNDER CARRIAGE 10.I !�. 2 FIRE ❑ IE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 2 m M 2 SYTM IN ENGAGE15-OTHER 4 ❑Y ®S NE DUNK VEH. O AT CRASHD 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF & i�6 �i 4 COM VEH 0 Ea 1 0 ALGONQUIN IL 60102 0 1 0 FIRST CONTACT 11 7_: __5 *IfYes.SeeSidebar U1 Z EJ58225 IL 2025 E TELEPHONE IL D 0 1 FMCU9G64NUB15759 PROGRESSIVE ❑Y ®N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR --1 SEALS. KIWAUN. D. 979358139 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 73 x DRIVER ❑ PARKED ❑DRIVERLESS 0 PEO ❑PEDAL ❑EWES ❑MAV 0 NOV 0 Dv !1 9 4 8 Chevrolet S10 2002 00-NONE 10''1 12 (,-2 FIREDUE O CRASH 0 ® U2 2 C o 13-UNDER CARRIAGE c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TtOP 3 X ❑Y i N 0 UNK VEH. AT CRASH 99-UNKNOWN O *Oistractlon Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s-.;, 6 j1:, 4 COM VEH ❑ ® U1 CO FIRST CONTACT 4 7 ,�5 •If Yes.See Sidebar I- ELGIN IL 60120 0 1 0 2106686B IL 2025 RFJ 0 IL D 0 1 GCCS19W728195068 STATE FARM ❑Y 123 N RDEF 73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same 0239236SFP13 BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 < Refused RESPONDER 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 ❑Y U2 Z co N 1 El 11 1 07/28 /2025 02 39 ®PM in a Work Zone? ®N DIRP > 1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 1 C) Si T 2 04 2 r / ❑PM ❑Construction * Z 3 0 xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM ❑Maintenance U2 a COLLINS.SATI NO 11-709-A W1519-000373 / / PM ' -, ARREST NAME ❑ o U 1 ® 11 1 CITATIONS ISSUED 0PENDING TIME • ❑Utility SLMT o NSECTION CITATION NO. ROAD CLEARANCE 0 AM 30 Ti 2 ❑ ARREST NAME Castaneda. Francisco 12-208-B W1519-000374 / / PM 0 Unknown work zone type U1 D' n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 - ❑AM Workers present? ❑Y 30 1519-Bae2 a.Guadalupe 401 / / ❑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 -' I. INDICATE NORTH combination):or .Z-1 1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C (example:shuttle or charter bus):or n X I- I- --I-- ��7131- r r 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 rter- y a van type < <.___a----� J t 1 - - _ ,� 4alsuosedord�llnatedtotransehrtbetweeicle or n9andr15r) ssen rs,including[hedriver. C — - a } } } for direct compensation(example:large van used for specific purpose):or L i[11 -I t i L I L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m . placarding(example:placards will be displayed on the vehicle). XI CARRIER NAME Z Not To Sortie - -- 6) ADDRESS ewde ry ersv I C CITY/STATE/ZIP 00 MOTOR CARR.ID 0 Interstate 0 Intrastate 0 I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other I. --- --• - USDOT NO. ILCC NO. m XI Source of above z . 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 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 White u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO: _ 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