HomeMy WebLinkAbout2025-00053920 ILLINOIS TRAFFIC CRASH REPORT sheet 1 Df 6 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV XO03928637-
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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 ❑$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
0 AMENDED YR 2025I 2025-00053920 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 m
® ❑ RELATED ❑Y ®N 08 18 2025 ❑AM ❑YES ®
PRIVATE NO U1
N LIBERTY ST Elgin mo /day/yr 05:25 ®PM FLOW CONDITION m
0(� COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 cn
01 C.7!MI N E O W Lillie St WITH VEHICLES INVLD ❑ STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑Y ® N PEDALCYCLIST®N ® FREE FLOW # LNS 0
18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EOUES 0 Nuv 0 Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
FOR DAMAGEDAREA(S) FROM TOWED U1 Q
Guerrero Ortiz. Roberto 1 1 /
yr 13-UNDER CARRIAGE 10 , 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14--TOTAL(ALL) DISTRACTED 0 ]$I U2 2 m
M 2 OTHER
4 ❑Y ®SYSNEM IN DUNK VEH. O AT CRASH O 99-UNKNOWN 9 76.70P 3 ,Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, ii_6 I,.4 COM VEH 0 Ea 1 0
~ ELGIN I L 60123 0 1 0 FIRST CONTACT 12 7 ; _5 *Irves.See Sidebar U1
Z 3953716B IL 2025 REAR
TELEPHONE
IL Other 1 GTEC14V45Z219443 Progressive ❑v ®N U2 m
B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
co
99 9 Guerrero Ortiz.Juan Luis 995634262 2 m
17
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 Ai
g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uv 0 NOV 0 Dv
�2 0 0 7 Nissan Sentra 2019 00-NONE O QI-O DUE TO CRASH ❑ 2
0 13-UNDER CARRIAGE 10( I 2 FIRE ❑ ® U2 C
M 2 4 SYSTEM IN 0 ENGAGED 0 ®-OTHER 9,16-TOP 3 9 0 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istraellon Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S ?TN.i. 4 COM VEH ❑ ® Ut CO
FIRST CONTACT 6 O7 )OS C.
It Yes.See Sidebar C
ELGIN IL 60120 0 1 0 CS32402 IL 2025 REAR Si)0
IL D 3N1AB7AP3KY347563 American Freedom ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 X
99 9 Jackson. Leonardo. D. 12235132404 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1{ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 1 81 ,81 ,025 05 25 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
0 2 ❑ 08 03 / / ❑PM ❑Construction *
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Z 3 ❑ CITATIONS ISSUED PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5
-a, ARREST NAME Guerrero Ortiz. Roberto 11-601 747786 r r ❑PM SLMT
o U 1 ® 11 1 CITATIONS ISSUED 0 PENDING Utility
o N SECTION CITATION NO. ROAD CLEARANCE TIME AM• ❑
t 2 El ARREST NAME Guerrero Ortiz. Roberto 6-303-A 747787 81 r 81 ,025 06 10 0 PM El Unknown work zone type U1co
30
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1564-Rea. Desiree 301 391-Jacobucci 91 , 21 ,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
Untt at ADDITIONAL UNITS FORMS.
.- .. , - A CMV is defined as any motor vehicle used to transport passengers or property and: Z
r r 01. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
i- } _-- ; combination):or —I
INDICATE NORTH
111 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} l N - } (example:shuttle or charter bus):or 0
1 Pill„•. Not To Scale 1 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
transporter-usually a van type vehicle or passenger car):or
C
__ -- I.I - I. } } } •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
... L } } } t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
Q ( I placarding(example:placards will be displayed on the vehicle). XI
JiCARRIER NAMEI� ADDRESS 'Ow CITY/STATFJZIP.- - MOTOR CARR.ID ❑ Interstate ❑ Intrastate
- ❑ Not in Comm./Govt. 0 Not in Comm./Other 0
--—--1 USDOT NO. ILCC NO. C
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XI
Source of above z
. IDOT PERMIT NO. WIDELOADo ❑Yes 0 No =
TRAILER VIN 1 m
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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
White Blue
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
Redmons/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 Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE