HomeMy WebLinkAbout2025-00051536 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003918756
u, 1 u2 1 1 1 U116 U2 1 u, 1 u2 8 U, 12 u2 1 5 9 u, 1 U221 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT 0 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 ®OVER$1,500 El NOT ON SCENE(DESK REPORT) El B Injury and f or Tow Due To Crash
El AMENDED YR 2025I 2025-00051536 VEHT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED 0 Y ®N 08 09 2025 ®AM ❑YES ®NO U1 -<
400 FULTON ST Elgin PRIVATE mo /day/yr 00:52 ❑PM FLOW CONDITION m
00 ®!MI N E 0 W Gifford St and Fulton St COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR El SLOW 3 Cl)
Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS O
18:DRIVER t] PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NOV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FOR DAMAGEDAREA(S) ROM TOWED U1 Q
Rodri uez Perez.Ged M. 1 2 /
yr Q
13-UNDER CARRIAGE 10 i FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 0 DISTRACTED ❑ 0 U2 m
F 2 4 El ®N SYSTEM
❑UNK VEH. ATCRASHD 99-UNKNOWN 9 16•TOP 3 `Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ :i1 6 �i,4 COM VEH 0 Ea 1 0
~ ELGIN IL 60123 0 1 0 FIRST CONTACT 3 7_; __5 *IIYes.SeeSidebar U1
Z DK44974 IL 2026
TELEPHONE
IL D 1G1ZB5EB1A4142594 Unique Insurance Company ❑Y ®N U2 13 . m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same ILP2835392 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 2 ou
❑ DRIVER X. PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 NW 0 NOV 0 DV
yr Toyota Sienna 2018 00-NONE „ '12 _, DUE TO CRASH ❑ ® 1 a7
o 0 ® SPDR 13-UNDERCARRIAGE FIRE El El U2
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O 2 DISTRACTEDC
a SYSTEM IN ENGAGED 15-OTHER 016-TOP 3
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 0�iII _ I 4 COM VEH D ® Ut CO
F,,, FIRST CONTACT 10 l:!1_t°( _5 •It Yes.See Sidebar C
AW69662 IL 2025 I 0Si)
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
5TDDZ3DC4JS20663 USAA ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Hislip. Daniel USAA0092318557102 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
{UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)!{TELEPHONE) (EMS) (HOSPITAL)
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 0 18 1 08/09 ,2025 00 52 ®❑PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 ® 18 1 10 30
! / ❑PM. ❑Construction *
R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM 0 Maintenance U2
a ® 11 1 ARREST NAME Rodriguez Perez.Gedy. M. 11-601 1550-000120 / ! El PM SLMT
o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
30
t 2 ARREST NAME AM
7 1 r ❑❑PM 0 Unknown work zone type U1
% El
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 30
1550-Camacho.Oscar 301 09 ,09,2025 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 e-----e••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
A 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
' }-----I-- --' 1 - INDICATE NORTH combination):or -I
N avan.,rx
r Y7'. BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
- } (example:shuttle or charter bus):or 0
L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier O
I
} } } transporting employees in the course of their employment(example:employee X
.mmm.�n. vnr I transporter-usually a van type vehicle or passenger car):or w
L L.___a__. 4. Is used ordesi natedtotrans transport passengers,including y} } } g po specific
p rs,includi the driver,
I for direct compensation(example:large van used fors cific purpose):or
. O
i. i 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires a 13
I placarding(example:placards will be isplayed on the vehicle).
m
CARRIER NAME Z
Fi0i98t ADDRESS
w
o
CITY/STATE/ZIP g
Not To Scale I - i. i. i. i. MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T 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' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Blue White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
_Redmons/Owners Residence . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE