HomeMy WebLinkAbout2025-00051662 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets Mill III H IIII
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X403919834
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
❑AMENDED ❑ B Injury and f or Tow Due To Crash YR 202512025-00051662 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
KI M BALL ST Elgin05:44
® ❑ RELATED ❑Y ®N 08 09 2025 ❑AM ❑YES El NO U1 -<
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION MFT!MI N E S W CENTER ST COUNTY PROPERTY ❑Y ® N DOORING ICIy #OF MOTOR 0 SLOW 2 fA
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
CO 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 uuv 0 Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
0 3 2012
FOR DAMAGEDAREA(S) TOWED U1
Infiniti G37X 00-NONE DUETOCRASH ❑
NAME(LAST,FIRST,M) Dominguez Garnica.Gregorio.G. mo / / FRMaof yr 11-_ 12 E
13-UNDER CARRIAGE 101 !! 2 FIRE 0 NI
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 M
M I 2 4 SYTM❑Y ®SNE DUNK VEH. 0 AT CRASH 0 99-UN 15- KNOWN THER9 16•TOP�3 `Distraction Value 9 ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6_iL 6 if.4 COM VEH 0 Ea 1 0
~ ELGIN I L 60120 0 1 0 FIRST CONTACT 3 7_; _-5 *II ves.See Sidebar U1
Z EV59395 IL 2026 E
TELEPHONE
IL D 0 J N 1 CV6AR4CM970898 Allstate ❑v ®N U2 I'
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST.M) POLICY NUMBER RSUR m
99 9 Dominguez. Ricardo 9758010173 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER
2 73
m g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑iiuv 0 i v ❑Dv
!1 9 yf 1 General MotorSiQoq 2019 00-NONE 0' t2.._1 DUE TO CRASH ❑ ! l 2 73
o 13-UNDER CARRIAGE 10 I 2 FIRE 0 ® U2 C
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y NJ N DUNK VEH. AT CRASH 99-UNKNOWN *Oistrac Dn Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8
:, 4 COM VEH ❑ ® U1 CO
FIRST CONTACT 11 TA-1:._5 •If Yes.See Sidebar
i ELGIN IL 60120 0 1 0 3014571 B IL 2025 REAR-
0 0 N
IL D 0 3GTU9BED3KG143408 State Farm ❑Y ®N RDEF 73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
99 9 Guerrero Ramirez.Juan 3615608SFP13 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE:ZIP
U1 =
(UNIT) (SEAT) (D081 (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 3 1 0 / F 1 3 0 1 0
m
/ / #OCCS D
7)
/ / UI 2 D
/ / 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
u 1 ® 11 1 08/09 l2025 05 44 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
o"
2 ❑ 20 99 1 1 ❑PM ❑Construction *
1
R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM ❑Maintenance U2
o1 ® 11 1 ARREST NAME Dominguez Garnica.Gregorio.G. 11-709-A W1924-000430 / ! El PM SLMT
o N •
❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
30
t 2 0 ARREST NAME AM
1 r ❑❑PM 0 Unknown work zone type U1
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ ❑AM Workers present? ❑Y 30
1524 Silva Jose 101 391-Jacobucci r ! ❑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.
A CMV is defined asmotor vehicle used to transportand:
r ----,5-••--, ; any passengers or property
Z
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
} i.-- -i-- --; } } } r -, , ; ; , 1, ( INDICATE NORTH combination):or —I
p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ' i 1 , } (example:shuttle or charter bus):or
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3. Is
. L.___A_. 1 ..._- - J transporting edmployeeslIn5 hecourseeo theire rsmployment example:employeener
} } }
transporter-usually a van type vehicle or passenger car):or co
< <.__-a-_-_, , l• < <--_-a-___� , , , , 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or 0
L L___-a____.: L L L ...._-..:_____� t i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). XI
--I
CARRIER NAME Z
ADDRESS 0
T.
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other O
USDOT NO. ILCC NO. m
XI
Source of above z
. 0 Yes 0 No ❑ Unknown A
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 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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE