HomeMy WebLinkAbout2025-00052174 ILLINOIS TRAFFIC CRASH REPORT sheet 1 Of 4 Sheets 01111101111 I011011001 I I
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X403919996
u, 1 U21 2 4 1 U1 2 U2 1 U, 1 1_12 1 U, 1 U2 1 5 15 u1 7 U2 1 *P 0119*
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 ❑$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 202512025-00052174 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 71
® ❑ RELATED ®Y 0 N 08 11 2025 ❑AM ❑YES ®NO U1
W CHICAGO ST Elgin 08:52
_ _ g PRIVATE mo !day!yr ®PM FLOW CONDITION m
FTlMI N E S W N EDISON AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 cn
❑ Kane HIT&RUN ❑V ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 --I
El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑uuv ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 n
0 8 !
yr 13-UNDER CARRIAGE 10.I 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 0 m
M 2 4 ❑Y ®SNEM❑UNK VEH. 0 AT CRASHD 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s,;il 6 4 COM VEH 0 ZgJ 1 0
ELGIN IL 60123 0 1 0 FIRST CONTACT 12 7 ;1 _5 *IIYes.SeeSidebar U1
Z FB40264 IL 2025 E
TELEPHONE
IL D 0 1 G1 PG5SB8F7281964 American Alliance ❑Y ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same I LAA1026471 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF`Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 73
m g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 IIIAV 0 i v 0 Dv
!2 0 0 0 Hyundai Elantra 2012 00-NONE „ " 12 "_, DUE TO CRASH rg ❑ 2 73
o yr 13-UNDER CARRIAGE FIRE 0 El U2
c
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 016•TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistrac)i n Value U1 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 0�i 6 lL,_4 COM VEH ❑ ® co
F,,, FIRST CONTACT 9 l:!:_�_O ._5 •IfYes.See Sidebar
ELGIN IL 60123 0 1 0 584AC627 IL 2025 " 0 Si)
Z
IL D 0 SNPDH4AE8CH151185 Illinois Vehicle Auto Ins ❑Y 123 N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
99 9 Same 12AU001501706 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 08(11 l2025 08 52 ®PM 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 ❑ 11 1 2 99
( r ❑PM• ElConstruction *
R 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM ❑Maintenance U2
-a, ARREST NAME Gonzalez Canales. Eriberto 11-901-A 1515-000722 r ! El PM SLMT
o U 1 ® 11 1 El CITATIONS ISSUED 0 PENDINGTIME 0• Utility
o N SECTION CITATION NO. ROADCLEARANCE DI AM 30
t 2 ❑ ARREST NAME Stultz.Sarah. M. 6-101-A 1515-000723 ( r PM ❑Unknown work zone type U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 30
1515-BellEck.Stacy 601 269-Mendiola 09 (02(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 ----r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
`----'-----; L. - ) INDICATE
ARROW NORTH
comWrtation):or .Z�1
` a I
I - 2 Is used or designed to transport more than 15 passengers including the driver C
N (example:shuttle or charter bus):or
I Not To Scale j _ transporting mployeeslin 5 hecourseer o their mers ployment example:employeener
} } }
L L.___a.._.� transporter sed or desy a van type ignated nated to transehicle or rt between9andr 15 passengers,ssen rs,including the driver. 03
I � ._ )n } } }
•
for direct compensation(example:large van used for specific purpose):or
L L.._.a.....l - - L L 5. Is anyvehicle used to transport anyhazardous material(HAZMAT)that requires m
m
i - -I placarding(example:placards will be displayed on the vehicle). ;p
I I
I .. r T : : : : :
ill - CARRIER NAME Z
ADDRESS 'n
CITY/STATE/ZIP C)
MOTOR CARR.ID 0 Interstate 0 Intrastate O
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
;....Y. ...; USDOT NO. ILCC NO. m
XI
Source of above z
. 0 Yes iJ 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 VIM 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
Blue Black
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 DAMAGE EXTENT: 3 TOWED BY/TO:DUE TO ® DISABLING DAMAGE Redmons VEHICLE CONFIG._CARGO BODY TYPE LOAD TYPE