HomeMy WebLinkAbout2025-00052034 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 m011011001 10
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X403915888
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INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 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 ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
0 AMENDED YR 2025I 2025-00052034 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
® ❑ RELATED ®Y 0 N 08 11 2025 ®AM ❑YES ®NO U1 -<
S STATE ST Elgin10:37
_ _ g PRIVATE mo !day/yr ❑PM FLOW CONDITION m
FT!MI N E S W WALNUT AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 1 cn
❑ Kane HIT&RUN ❑V ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 --I
Igi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
FOR DAMAGEDAREA(S) FROf'tf�TOWED U1 I�
PONCE. ERIC 05 !
yr 13-UNDER CARRIAGE 10 1 2 FIRE 0 NI
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 4 <<Tl
M 2 SYTM IN ENGAGEis-OTHER
4 ❑Y ®S NE DUNK VEH. O AT CRASHD O 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF & it 6 4 COM VEH 0 j$J 1 0
~ ELGIN IL 60120 0 1 0 FIRST CONTACT 12 7_;1 __S *IrYes.See Sidebar Ut
Z CZ44612 IL 2022 REAR
TELEPHONE
IL D 0 WBAAV33491 FU98538 Bristol West ❑Y ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same G01669048900 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 0
�{ DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑NMv 0 NCv 0 DV
!1 9 6 2 Toyota Highlander 2024 00-NONE 11_-1 12--_1 DUE TO CRASH ❑ 21 98 xi
o - 13-UNDER CARRIAGE 10� 2 FIRE ❑ ® U2 C
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X
❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value 9 0
POINT OF 8 4 COM VEH D ® ut CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6 1'
FIRST CONTACT 6 O7 �:I-Q'_OS •If Yes.See Sidebar
Bolingbrook IL 60440 0 1 0 EN19261 IL 2026 aR 0
IL D 0 STDKDRBH4RS544368 National Union Fire Ins ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
Elgin Fire Union Leasing Trus CA5309780 BAC 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)
U2 996 r
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##occs y
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
u 1 ® 11 1 81 / 11 /025 10 37 ®❑PM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1 C)
2 ❑ 28 99 81 /11 /025 10 47 ❑PM ❑Construction
E
F.; 1
R 3 ❑ ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMSARRIVEO TIME 1
z J ®AM ❑Maintenance U2
-a, ARREST NAME PONCE. ERIC 6-101* 1549000185 81 /11 /025 10 52 ❑PM SLMT
o U1 ® 11 1 •
ljgCITATIONS ISSUED 0 PENDING - Utility
S' NSECTION CITATION NO. ROAD CLEARANCE TIME AM• 0
T 2 ❑ ARREST NAME PONCE. ERIC 11-601-Ax 1549000186 81 /11 /025 10 50 [fl PM 0 Unknown work zone type U1 30
2 2 3 0 OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1549-Brown. Bryan 601 269-Mendiola 91 / 12 /25 09 00 ❑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
a1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
i- -----'-----' A I r INDICATE NORTH combination):or -I
I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} - } (example:shuttle or charter bus):or3. Is designed to car 15 or fewer ssen ers and o rated a contract carrier O
< <. A_._.� / L.:
} } } transporting employees In the course of their employment(example:employee73
transporter-usually a van type vehicle or passenger car):or co
L 4. Is used or designated to transport between 9 and 15 passengers,including C}--- ----; - } } g Po passen rs,includi the driver,
for direct compensation(example:large van used for specific purpose):or o
i 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
a _ placarding(example:placards will be displayed on the vehicle).
2#
Walnut/Ave CARRIER NAME Z
l - ADDRESS
o
D
Not To Scale I I '
C
CITY/STATE/ZIP g
I i - i. i. i. i. MOTOR CARR.ID 0 Interstate ❑ Intrastate
I I T I ❑ Not in Comm./Govt. ❑ Not in Comm./Other
0
--- --1 - USDOT NO. ILCC NO. m
XI
Source of above z
.
Were HAZMAT placards on vehicle? 0 Yes 0 No =
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
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Silver 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/Owners Residence . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE