HomeMy WebLinkAbout2025-00053385 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
011011001 011 01111 0
DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY *X003924972*
u, 9 U2 1 1 1 U, 9 U2 U199 u2 U199 U2 1 1 9 U123 U221 *P 0119*
INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 7
VEHICLE/PROPERTY El OVER$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 2025I 2025-00053385 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m
165 DUNDEE AVE El10:56
® ❑ RELATED ❑Y ®N 08 16 2025 ®AM ❑YES ®NO U1
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
COUNTY PROPERTY ''Y ❑N DOORING ❑y #OF MOTOR El SLOW 2 fA
❑ FT!MI N E S W Kane HIT ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I
&RUN
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Qg3 DRIVER O PARKED O DRIVERLESS 0 PED p PEDAL 0 EWES 0 NW 0 Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 1 0
/ ! FOR DAMAGEDAREA(S) FROPtf TOWED U1 0Unknown.O. Unknown Unknown 00-NONE EN
it.. 12 , OUETOCRASH ❑
NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE IE
fo !!. 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED U2 1 <
9 9 SYSTEM IN 9 ENGAGED 9 15-OTHER 9 16.TOP 3 ❑ _
❑Y ❑N ®UNK VEH. AT CRASH ®-UNKNOWN $ 4 `Distraction Value 9 ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF
1— FIRST CONTACT 99 7_•L B �i COM VEH 0 0 1 0
2 Z ;— __5 If Yes.See Sidebar U1
0 9 0 UNKNOWN " _, 0
_ TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1)
Unknown ❑Y ❑N U2 m
B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
co
99 9 Same Unknown 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF`Y OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 99 0
0 DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMV 0 NOV 0 DV CIRCLE NUMBER(S) U1
yr 1(I t2 _1 ❑ Ill 2 ,C
0 ID El-UNDER CARRIAGE 10 1 E FIRE U2
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR n
SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP 3 a ❑ 9
Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistractlon Value
POINT OF 8 j 4 U1
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT OO Y�I-®�zl�s •CIO f VEH
® C
CO
H 3609709B IL 2025 0 Si)
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
1 FTFW1 CT5DKG31 499 State Farm 0 Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Gutierrez Cintora. Manuel 0493692SFP13 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (008) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 18 1 08,16 /2025 10 56 ®❑pm in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 0 30 99
N 3 0 ❑CITATIONS ISSUED 0 PENDING • + ! ❑PM ❑Constrtiction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 7
—a, ARREST NAME / / ❑PM
o N 1 ® 11 1 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT
15
t 2 0 ARREST NAME AM
7 1 r ❑❑PM ❑Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 — ❑AM Workers present? ❑Y 15
1 Lundvick.John 301 , / 0 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 INLVED,USE SR 1050A
ADDITIONAL UNITVOS FORMS.
r ----r••--, , t A CMV is defined as any motor vehicle used to transport passengers or property and: Z
Not To Scale I � . 01. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -
c ` --I -' r INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- r r r (example:shuttle or charter bus):or
. A r 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
yr' - } } } transporting employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
•__ -- - �_ ` - •} } } 4. Is used or designated to transport between 9 and 15 passengers,including the driver, C
\ for direct compensation(example:large van used for specific purpose):or 0
} } } _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). XI
—1
CARRIER NAME Z
ADDRESS 0
w
C)
CITY/STATE/ZIP g
,enm,..nn. - i. MOTOR CARR.ID 0 Interstate 0 Intrastate
I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other
‘I. - --1 - USDOT NO. ILCC NO. m
XI
Source of above z
. • m
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
Black
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