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HomeMy WebLinkAbout2025-00051614 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 011011001 0111100OOI1 III HI DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV xoo391336 u, 1 U211 2 4 1 U1 2 U2 1 U, 1 1_12 1 U, 1 U2 1 1 15 U1 1 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 14 VEHICLE/PROPERTY N OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash El AMENDED YR 202512025-00051614 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn ST CHARLES ST El In12:34 ® ❑ RELATED ®Y 0 N 08 09 2025 12,— ❑YES N NO U1 -< _ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION m FT!MI N E S W DWIGHT ST COUNTY PROPERTY ❑Y 2 1 N DOORING Ely #OF MOTOR El SLOW 1 (n ❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I O AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0 0 7 / yr 13-UNDER CARRIAGE 10.I • 2 FIRE 0 IE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 0 m M 2 SY 15-OTHER 5 ❑Y ®SNE DUNK VEH. O AT CRASH M IN D O 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s,;ii_6 I..4 COM VEH 0 g 1 0 F. Lake In The Hills IL 60156 0 1 0 FIRST CONTACT 12 7 ; _5 *IIYes.See Sidebar U1 Z DC71421 IL 2025 REAR TELEPHONE IL D 0 7FARW2H81 ME028901 Safeway Insurance ❑Y I l N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same 3854948-I L-PP-002 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ® N 2 XI Eg DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED 0 PEDAL 0 EWES 0!My 0 Ncv 0 DV !1 9 9 4 Hyundai Elantra 2013 00-NONE 0.,. z i-0 DUE TO CRASH rg ❑ 2 x o yr 13-UNDER CARRIAGE 9I ©Ic 2 FIRE ❑ N U2 C II F 2 8 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istracton Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 -'iI�1:, 4 COM VEH 0 N U1 CO FIRST CONTACT 11 7 _5 •If Yes.See SidebarC n ELGIN IL 60120 B 1 0 BA30413 IL 2025 IL D 0 5NPDH4AE6DH357767 Progressive ❑Y N N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Elgin Fire 99 9 Palacio.Omar.A. 984042134 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (DOBI (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) :A / / UI 1 D / / 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 N 11 4 81 ,12 /25 12 34 ®pm in a Work Zone? NCI N DIRP co 1 t PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 7 C) T 0 2 0 2 23 , , 0 PM ❑Construction R 3 0 $I CITATIONS ISSUED El PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM 0 Maintenance U2 -a, ARREST NAME Salazar Tinoco.Alexander. M. 11-901-A 1548-98 , ! ❑PM SLMT oN 1 ® 11 4 N CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM' ❑Utility t 2 El ARREST NAME Salazar Tinoco.Alexander. M. 11-1204-B 1548-99 81 ,12 ,25 12 50 ®PM 0 Unknown work zone type U1 30 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM ❑Y 30 1540-Allahi. Muhammad 401 91 , 12 ,25 01 30 ❑PM Workers present? ®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 Bf.7Cherlee78t ADDITIONAL UNITS FORMS. r ----r••--, , I A CMV is defined as any motor vehicle used to transport passengers or property and: Z a 01. Has a weight rating more than 10,000 pounds(example:truck or truck/trailer -< ` ` -'- -' r INDICATE NORTH combination or .Z-1 © I BY ARROW 2 Is used or designed to transport more than 15 C g sp passengers including the driver n } r r r (example:shuttle or charter bus):or 0 L -Jr- I 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 } I• } transporting employees In the course of their employment(example:employee 73 rter- y a van type L L.___a__._I. c I 4alsuosedord�llnatedtotransehrtbetweeicle or n9andr15pssen rs,includingthedrver, C `v , © ` } } } for direct compensation(example:large van used for specific purpose):or 0 L L--_-a-___4 ` SS ) CrT ' — - i. < i. 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m D*1 it7St— — — Unit 1 —U nit 1� d)—U t I t placarding(example:placards will be displayed on the vehicle). XI —01 I 11 I - , _- , CARRIER NAME Z ADDRESS 0 i. n CITY/STATE/ZIP g I } I - MOTOR CARR.ID 0 Interstate ❑ Intrastate I I T I I I N ❑ Not in Comm./Govt. 0 Not in Comm./Other O Not To Scale J 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 iO No 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 VIM 1 m LOCAL USE ONLY TRAILER VIN 2 m 0 TRAILER WIDTH(S) 0-96" 97-102" >102' -n TRAILER 1 ❑ ❑ 0 Z 1-1 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 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