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HomeMy WebLinkAbout2025-00051202 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I011011001 I 101 DII DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY xoo�J1r2 3 u, 1 U21 2 4 1 U1 2 U2 1 U, 1 u2 1 U, 1 U2 1 1 10 U1 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 2 VEHICLE/PROPERTY N OVER 51,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash El AMENDED YR 2025I 2025-00051202 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn WING ST El In 03:40 ® ❑ RELATED ®Y 0 N 08 07 2025 ❑AM ❑YES ®NO U1 _ _ g PRIVATE mo /day/yr NPM FLOW CONDITION m FT!MI N E S W LASALLE ST COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 15 u) ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ 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 EDUCE 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n �TOWED U1 Q mo Perez. yr 13-UNDER CARRIAGE I ' FIRE 0 IE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 2 DISTRACTED ❑ 0 U2 4 M M 2 4 El ®SNE❑ n 15-OTHER UNK VEH. ATCRASHIN n ENGAGED 99-UNKNOWN 9 76•TOP 3 `Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, it 6 Ii COM VEH 0 0 1 n I- FIRST CONTACT 11 7__ --_;__5 *IIYes.See Sidebar U1 0 Z ELGIN IL 60120 0 1 0 FP204176 IL 2026 REAR TELEPHONE IL D 0 3N1CP5BV7LL51621 National Union Fire Insur ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Oreilly Auto Parts.Oreilly 6890203 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 98 0 m x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NUR 0 i v 0 Dv yr Q 2 !� �1 0 13-UNDER CARRIAGE 10 j ©( 2 FIRE ❑ ® U2 C F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16•TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN •0istrac i n Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-it 6 1l, 4 COM VEH ❑ N U1 CO FIRST CONTACT 1 Y _, _5 •(ryes,See SidebarC H ELGIN IL 60120 0 1 0 FE94425 IL 2026 I 0 M IL D 0 2G NAXYEXXL6272532 Farmers ❑Y 123 N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = LUJAN. BARTOLO.S. G01349809204 BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE:ZIP 996 < Refused RESPONDER U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(A.DDRESS)/(TELEPHONE) (EMS) (HOSPITAL) U2 m ##OCCS y / / U1 1 D / / 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 08,07 /2025 03 40 ®pm in a Work Zone? NCI N DIRP co 1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U157 1 C) T 2 ❑ 2 06 / / ❑PM ❑Construction * Z 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM ❑Maintenance U2 o ® 11 1 ARREST NAME Perez.Carlos 11-901-A S1526000609 / / ❑PM SLMT o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑El AM Utility r 2 El ARREST NAME 08/07 /2025 04 30 0 PM ❑Unknown work zone type U1 30 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 30 1526-Walsh.Jacob 602 08 /26/2025 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 INDICATE NORTH combination):or .Z-1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } 0 - } (example:shuttle or charter bus):or 0 I- -A---•i 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 - - - transporter-usually a van type vehicle or passenger car):or w L }-----}----; 2 - } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver, nu — for direct compensation(example:large van used for specific purpose):or 0 L L--_-a-...� 1t < < i L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires III placarding(example:placards will be displayed on the vehicle). ;p CARRIER NAME Z I - ADDRESS Nor Tb Scala ' I Lamest D rn t n CITY/STATE/ZIP 0 MOTOR CARR.ID 0 Interstate 0 Intrastate 0 1 1 r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other ; _Y_ __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 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 Black 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