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HomeMy WebLinkAbout2025-00053202 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets Mil l III H IIII 11111111 110001001 lIlIflIflHIl DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003924777- u, 1 U21 1 1 1 U116 U2 1 U, 1 1_12 1 U, 1 U2 1 1 11 U1 1 U211 *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 El$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 2025-00053202 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 -n RT20 EB El In 03:58 ® ❑ RELATED ❑Y ®N 08 15 2025 ❑AM ❑YES ®NO U1 -< g PRIVATE mo !day!yr ®PM FLOW CONDITION m 5 !MI N E S COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 15 t�A ® © Shannon Pkwy Kane HIT ❑V ® N WITH VEHICLES INVLD IN STOPPED U2 --I &RUN 0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 /8:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 FOR DAMAGED AREA(S) .FROM TOWED U1 0 Alvarez. Emmanuel.Y. 0 5 / yr 13-UNDER CARRIAGE 10. EN 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL)THERDISTRACTED ® 0 U2 2 m M 2 4 SYTM❑Y ®SNEDUNK VEH. 0 ATCRASHD 99-UUNKNOWN 9 16•TOP 3 `Distraction Value 5 ALGN X. r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, it B �i 4 COM VEH 0 El 1 0 �- Berwyn I L 60402 0 1 0 FIRST CONTACT 1 7_; __5 *II Yes.See Sidebar U1 Z rwy S655990 IL 2025 REAR TELEPHONE IL D 0 1 GAWG PFAXB1159810 Progressive ❑Y IlN U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Elgin Fire 99 9 Ebert.James. M. 00579265 1 o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 98 rg- x DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 NMv 0 NCV 0 DV !1 9 9 6 Toyota 4Runner 2018 00-NONE 11_"j Q1,-_1 DUE TO CRASH rg ❑ 2 x oy Yr 13-UNDER CARRIAGE 10) I 2 FIRE 0 ® U2 C M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value 9 0 POINT OF s i COM VEH 0 ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6 FIRST CONTACT 7 v. ,�=QI_5 •If Yes.See Sidebar Round Lake IL 60073 B 1 0 DW18685 IL 2026 I AR 0 N Z IL D 0 JTEBU5JR4J5588704 AAA ❑y 123 N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Elgin Fire 99 9 Same AUT702105035 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 < Provena St.Joseph RESPONDER U1 = (UNIT) (SEAT) (DOE) (SEX) {EAR') (AIR) (INJ) 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME))(ADDRESS))(TELEPHONE) (EMS) (HOSPITAL) 1 3 07 / 2 :A / / UI m / / 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 El 11 1 81 ,5/ /025 03 58 ®AM in a Work Zone? ®N DIRP co 1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 4 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 2 0 28 41 81 ,51 ,025 04 15 ®PM ❑Construction " 3 0 $I CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 4 ❑AM ❑Maintenance U2 o 1 ® 11 1 ARREST NAME Alvarez. Emmanuel.Y. 11-601 S1542-000399 81 ,51 /025 04 26 Igi pM• • El SLMT igi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM Ti 2 0 11 1 ARREST NAME Alvarez. Emmanuel.Y. 3-414 W1542-000401 8/ /51 /025 05 00 0 PM 0 Unknown work zone type U1 45 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 45 1542 Chafe. Ethan sot 91 , 61 ,025 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 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< c ` ''- ' r INDICATE NORTH combination):or -I 1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C i_ :: _ (example:shuttle or charter bus):or C) 4� rrrt a `�,� 3. Is designed to car 15 or fewer ssen ers and o rated a contract career O < }.___A.._.� ._ .. 1 aar sCSb , y } } } transportingemployees In thecoursee of their employment pbyment(example:employee 1 �`-Kcu ?�_ b�.... - 1 VanSpOrtet-usually a van Type vehicle or passenger car):or �M'� "` } } } 4. Is used or designated to transport between 9 and 15 passengers,including the driver, w ,,,,.. ` for direct compensation(example:large van used for specific purpose):or O L____a..... s>' ` _ L t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m : . . . placarding(example:placards will be displayed on the vehicle). XI Z f: CARRIER NAME Z ,� � ♦ ADDRESS D -sr / rA f> i. i. i. i. n - 4. CITY/STATE/ZIP 0 '. < MOTOR CARR.ID ❑ Interstate ❑ Intrastate I . ❑ Not in Comm./Govt. 0 Not in Comm./Other ; _Y_ _-1 - 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 0 TRAILER WIDTH(S) 0-96" 97-102" >102' -n TRAILER 1 0 0 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w White Gray 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: 3 TOWED BY/TO: DUE TO ® Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE