Loading...
HomeMy WebLinkAbout2025-00051507 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 1111111 H IIll DIII 001100001001 HIll 111111011 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003924979 u1 9 U2 U1 2 4 1 U1 2 U2 1 U1 1 U2 1 U1 1 U2 1 4 15 U1 1 U2 1 .P0119* 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 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash 0 AMENDED YR 2025I 2025-00051507 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 m SUMMIT ST El In09:33 ® ❑ RELATED ®Y 0 N 08 08 2025 ❑AM ❑YES ®NO U1 _ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION m FT!MI N E S W CENTER ST COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR El SLOW 3 Cl) ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N 51 FREE FLOW # LNS 0 Qg3 DRIVER t] PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n 0 7 / yr 13-UNDER CARRIAGE ©, i-O FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O 2 DISTRACTED 0 0 U2 4 <<Tl M 1 SYTM 8 ❑Y ®SNE DUNK VEH. 0 AT CRASH 99-UUNKNOWN THER O9 t6-TOP 3 ,Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF ,)1 6 I,. COM VEH 0 LK 1 C) ~ ELGIN I L 60120 B 1 0 FIRST CONTACT 12 O_; __5 *If Yes.See Sidebar U1 0 Z EU56764 IL 2025 REAR TELEPHONE IL D 5N 1 AT2MV1 EC833479 Direct Auto ®Y ❑N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Elgin Fire Same PAI L001228644 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER !1 9 9 2 Dodge Caravan(inc Grand)2018 00-NONE O" 01'-O DUE TO CRASH rg ❑ 2 73 .. 13-UNDER CARRIAGE j I.( 2 FIRE 0 ® U2 C c F 2 8 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOPO3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN I O Oistracuonvalue 9 2 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8- 1. 6 Ii, 4 COM VEH ❑ El U1 CO FIRST CONTACT 3 7��'—_,SOS •If Yes.See Sidebar ELGIN IL 60123 A 1 0 EZ52640 IL 2026 IL D 2C4RDG EG7J R150477 State Farm ❑Y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X Elgin Fire Same 3579328SFP13 BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 < Sherman RESPONDER U1 = (UNIT) (SEAT) (DOER (SEX! {SAFT) (AIR) (INJ) 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 2 11 01 / LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y N 1 ® 11 1 Gutierrez. Luis. F. side of house 470 Center 08,08 /2025 09 33 ®AM in a Work Zone? ®N DIRP co 1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 2 0 470 CENTER ST ELGIN IL 60120 23 28 08,08 /2025 09 33 PM ® , ❑Construction * en R O ❑ El CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 3 ❑AM ❑Maintenance U2 o ® 11 1 ARREST NAME Young.Semaj. L. •3-707` 1554000154 08/08/2025 09 38 Igi pM SLMT ISI CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM• ❑Utility t 2 El ARREST NAME Young.Semaj. L. 11-503-A-1 1554000153 08/09 /2025 00 00 fl PM El 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 1554-Wagener.Vincent 102 269-Mendiola 08 ,26/2025 01 30 El 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 Not Fa SEW, I 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 - } (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 speific purpoe):or the driver. L L__-_a.___. T, si..^. st - t i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m placarding(example:placards will be displayed on the vehicle). ;p ,-T n — CARRIER NAME Z J o 470 __ ADDRESS D riiii" rn C) Oerrter7S1. CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate 0 Intrastate 0 I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other ‘I. - --1 - USDOT NO. ILCC NO. m XI 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 TRAILER 2 ❑ 0 0 o u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Blue White u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. Arties/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® DISABLING DAMAGE Arties/Impound.Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE