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HomeMy WebLinkAbout2025-00053985 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 011011001 01101100 DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X003928685 u, 1 U21 2 4 1 U146 U2 1 U, 1 1_12 1 U, 1 U2 1 2 10 U1 3 U2 4 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away Elgin Police Department ONE PERSON'S ®5501-51.500 ®ON SCENE 1 VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and f or Tow Due To Crash YR 2025I 2025-00053985 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn ® ❑ RELATED ®Y 0 N 08 19 2025 ®AM ❑YES ®NO U1 —< ST CHARLES ST Elgin05:28 _ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m FT!MI N E S W DWIGHT ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑Peoa_ ❑EWES ❑Nuv ❑ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0 Subaru Forrester 00-NONE FROM TOWED U1 NAME(LAST,FIRST,M) Hernandez-Mota. Magdalena mo yr 2009 13-UNDER CARRIAGE ©I O -1 DUE TO CRASH 0 EN FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 2 DISTRACTED ❑ 0U2 2 m F 2 SYTM 4 ❑Y ®SNE❑UNK VEH. 0 AT CRASH 0 99-U 15-UNKNOWN THER9 16•TOP 3 *Distraction Value ALGN X. r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF II, 4 COM VEH ❑ E! 1 0 ELGIN I L 60120 0 1 0 FIRST CONTACT 11 7_: __5 *llyes.See Sidebar U1 Z EW81639 IL 2025 REAR TELEPHONE IL D JF2SH61659H768628 Kemper ❑v igiN U2 13 , m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same 12RA000071242 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ® N 2 XI x DRIVER ❑ PARKED ❑DRIVERLESS 0 FED ❑PEDAL 0 EWES ❑ � !1 9 9 9 Honda Accord 2010' 00-NONE 0. ©' ®DUE TO CRASH ❑ 2 x o Yr 13-UNDER CARRIAGE 16 I f: 2 FIRE ❑ El U2 C Ti M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistrac) n Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6-it 6 11:,-4 COM VEH D ® U1 COFIRST CONTACT 12 7• _,_.5 •(ryes.See Sidebar n ELGIN IL 60120 0 1 0 BD12593 IL 2025 I:EaR 0 IL D 1 HGCP2F31AA163436 Allstate ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 = Same 811 259 518 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER u1 = KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(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 08,19 /2025 05 28 ®❑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 O 2 05 15 ( / CI Pm ❑Construction * R 3 ❑ ]yg CITATIONS ISSUED El PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM ❑Maintenance U2 —a, ARREST NAME Hernandez-Mota. Magdalena 11-601 378001716 ! ! ❑PM SLMT 1 ® 1 1 1 CITATIONS ISSUED 0PENDING Utility ran llSECTION CITATION NO. ROAD CLEARANCE TIME N AM ❑ o t 2 ❑ ARREST NAME Hernandez-Mota. Magdalena 11-709-A 378001717 081 19 ,2025 06 00 MPM ❑Unknown work zone type U1 30 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 30 378-Alcorn.Steven 401 331-Ziegler 09 , 15/2025 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 truck trailer -< ` ` ' ' r u ' r INDICATE NORTH combination):or 531 r BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C Not To Scale I _ (example:shuttle or charter bus):or 0 t X } A I 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 73 Itransporter-usually a van type vehicle or passenger car):or co L -----------; - I. } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver, to for direct compensation(example:large van used forspecific purose):or L L-. ..i.. --. J - t i. .. i. L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m ow/avar placarding(example:placards will be displayed on the vehicle). ;p — — — — — -UMW- - - - D VI - CARRIER NAME Z ADDRESS 0 n I CITY/STATE/ZIP _ i. i. i. i. 4. MOTOR CARR.ID 0 Interstate ❑ Intrastate ' ❑ Not in Comm./Govt. ❑ Not in Comm./Other 00 --- --4 USDOT NO. ILCC NO. C m XI Source of above z . If Yes,Name on placard O 4 digit UN NO. 1 digit Hazard class No. XI XI 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 ❑ 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 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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO. DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE