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HomeMy WebLinkAbout2025-00050201 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets III III 11 II Il DIII 01100100 HI 1101IIIII DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003910297 u, 1 U21 3 4 1 U1 2 U2 1 U1 1 U2 1 U1 1 U2 1 1 10 U, 3 U2 1 *P 0119 INVESTIGATING AGENCY DAMAGE TO ANY El 5500 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 1 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) El Injury and f or Tow Due To Crash El AMENDED YR 2025I 2025-00050201 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn ® ❑ RELATED ®Y 0 N 08 03 2025 ®AM ❑YES ®NO U1 -< SUMMIT ST Elgin11:02 _ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m FT!MI N E S W N LIBERTY ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n ❑ Cook HIT&RUN ❑Y ® N WITH VEHICLESOT, INVLD DO U2 —I Igl AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EouES 0 NW 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0 0 3 ! yr Reyes-Rodriguez.An el Mitsubishi Lancer 2016 00-NONE „. Q 0 DUE TO CRASH ® ❑ 13-UNDER CARRIAGE FIRE ❑ al STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED ® 0 U2 4 <<Tl M 2 SYTM IN ENGAGE4 ❑Y ®SNE DUNK VEH. O AT CRASHD O 99-UNKNOWN 9 16•TOP 3 `Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6,_iL 6 �i COM VEH 0 j$J 1 0 " �- SOUTH ELGIN I L 60177 0 1 0 FIRST CONTACT 1 T ; __5 *it Yes.See Sidebar U1 ZDF94003 IL 2025 E TELEPHONE IL D 0 JA32U2FU3G0001907 Progressive El ®N U2 I— i n EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Elgin Fire 1 99 9 Same 991241837 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER XI Refused ❑Y ❑ N 2 0 x DRIVER ❑ PARKED 0 DRIVERLESS ❑ FED ❑PEDAL ❑EWES ❑iiuv 0 i v ❑Dv !1 9 4 6 Cadillac SRX 2011 00-NONE al z j--_, DUE TO CRASH 0 ❑ 2 x 0mo 13-UNDER CARRIAGE 6 I ©). 2 FIRE El U2 C Ti M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 11:, 4 COM VEH El ® U1 CO FIRST CONTACT 11 7� , _5 •If Yes.See Sidebar H ELGIN IL 60120 0 1 0 CE43037 IL 2025 IL D 0 3GYFNCEYXBS567334 State Farm ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X Elgin Fire 1 99 9 Same 2206668-SFP-13 BAG E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPOND O N 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 0 Y U2 Z N 1 ® 11 1 08,03 l2025 11 02 ®❑PM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 2 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 � 0 2 ❑ 25 18 ) / ❑PM ❑Construction * R 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 ❑AM ❑Maintenance U2 a1 ® 11 1 ARREST NAME Reyes-Rodriguez.Angel 11-901-A 1561-000042 / ! El PM SLMT o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility 0 AM t 2 El ARREST NAME 08 r 03 l2025 12 45 ®PM El Unknown work zone type U1 3O 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30 1561-Sarovic• Mirko 201 237-Copland 09 ,05/2025 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 pounds(example:truck or truck/trailer 1. Has a weight rating10 000 INDICATE NORTH Ilon)o p0 yl BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } J - } r r r (example:shuttle or charter bus):or 0 . A I rw.w , 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 — — — — Unit 2 - transporter-usually a van type vehicle or passenger car):or w L •-----}----; TAIL': I - } } } •4. Is used or designated to transport between 9 and 15 assen passengers,including the driver. C .-. for direct compensation(example:large van used fors cific purpose):or to L L____a____. 1 i,`.'• 4 _ t i. .. i. t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m �::,. placarding(example:placards will be displayed on the vehicle). XI . 1 CARRIER NAME Z ADDRESS 0 T. il I•% I ( Not To Scale I to 0 CITY/STATE/ZIP g MOTOR CARR.ID ❑ Interstate ❑ Intrastate I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other -----------1 - USDOT NO. ILCC NO. rn XI Source of above z . ❑ 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' m TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Blue,Light White u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. Arties/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 Arties/Impound.Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE