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HomeMy WebLinkAbout2025-00051826 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets Ill III 11 II Il DIII 011001001111101111011��0 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X4G3919919 u, 9 u21 1 1 1 U, 9 U2 1 U199 1_12 1 U,99 U2 1 1 9 U123 U221 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW ' Elgin Police Department ONE PERSON'S ®5501-$1.500 ❑ON SCENE 7 VEHICLE/PROPERTY ❑OVER$1,500 ®NOT ON SCENE(DESK REPORT) ❑AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00051826 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 -11 840 N STATE ST Elgin01:12 ® ❑ RELATED 0 Y ®N 08 10 2025 DAM ❑YES ®NO U1 _ PRIVATE mo /day/yr ®PM FLOW CONDITION Ill COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR 0 SLOW 1 (n ❑ FT/MI N E S W Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I O AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Q83 DRIVER I] PARKED 0 DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 NW 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C) / / FOR DAMAGEDAREA(S) FROPtf TOWED U1 O Unknown.0. Ford Fusion 2013 00-NONE „ 12 , DUE TO CRASH ❑ EN NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 10 !�. 2 FIRE 0 IE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED U2 0 < 9 9 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 ❑ ' _ ❑Y ®N DUNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 9 ALGN r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 iI 6 ii COM VEH 0 121 1 C) I— 0 9 0 FIRST CONTACT 6 O7 ::L.Q_OS =If Yes.See Sidebar U1 0 Z DZ16949 IL 2026 REAR TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 3FA6POLU8DR251669 Unknown ❑Y ❑N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m TERRONES. EDGAR.A. Unknown 1 rn `o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY.STATE,ZIP PHONE NUMBER '‘.3RESPONDER ( C)) 0 DRIVER N. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 yr _ 13-UNDER CARRIAGE 10 ©l,, E FIRE ❑ ® U2 C c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR C) SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16 El -TOP 3 0 X a 0 Y N 0 UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value POINT OF 8 -4ut N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 12 7 '+�.6 COM•ISVSee Sidebar❑ ® CO H FM72462 IL 2026 REAR0 N M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 2G1 FA1 E32E9299805 Progressive ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Guc Caal. Nelson. R. 991218526 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = )INIT1 (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 2 1 1 2 / M 2 4 0 1 0 m / / #OCCS D 71 / / U1 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 ® 18 5 08,10 l2025 01 12 ®AM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 � 2 0 30 99 N 3 0 ❑CITATIONS ISSUED 0 PENDING + ! ❑PM, ❑Construction SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 1 -a, ARREST NAME / / El PM o u ER 5 0 • CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑utility SLMT 15 r 2 ARREST NAME AM T 1 / ❑❑PM 0 Unknown work zone type U1 El OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 - El Am Workers present? ❑Y 15 1547-Steele.Justin 501 , / ❑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 A ADDITIONAL UNITS FORMS. r ----r••--, , I A CMV is defined as any motor vehicle used to transport passengers or property and: z N Not To Scale 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 j. _ } (example:shuttle or charter bus):or X L A 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 L.___a._ 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including C} } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or 0 L t i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m a pMcarding(example:placards will be displayed on the vehicle). 21. e409N9SLate7St CARRIER NAME Z unp 1 ADDRESS 0 C) CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate 0 Intrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other ‘I. - --1 USDOT NO. ILCC NO. m Unit , 73 Source of above z . If Yes,Name on placard O 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 ill TRAILER 2 ❑ 0 0 o u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w White Red u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 9 TOWED BY/TO: _ . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO: DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE