HomeMy WebLinkAbout2025-00053998 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 1011011001 01
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003928700
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 El ON SCENE 1
VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
❑AMENDED YR 2025I 2025-00053998 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
695 S STATE ST Elgin07:37
® ❑ RELATED ❑Y ®N 08 19 2025 ®AM ❑YES ®NO U1 -<
_ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ FT/MI NESW Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS O
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 Nuv 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
09
! yr ++- .1213-UNDERCARRIAGE tUl NI
•, 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® 0 U2 2 m
M 2 4 SYTM❑Y ®S NE❑UNK VEH. 0 AT CRASH 99-UNKNOWN THER9 +6•TOP 3 `Distraction Value 4 ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ it B ii,4 COM VEH 0 g! 1 n
H F.
ELGIN I N I L 60123 7743 0 1 0 FIRST CONTACT 7 �_; __s *II Yes.See Sidebar U1 0
•• Z DH46705 IL 2026 REAR
TELEPHONE
IL D 0 JTNK4RBEOK3071674 State Farm ❑Y ®N U2 19 . m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
99 9 Same 0704841-SFP-13 2 m
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Refused ❑Y ® N 2 X
x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMv 0 Ncv 0 DV
!1 9 yf 1 Pontiac Vibe 2006 00-NONE O+ . 12..-_1 DUE TO CRASH 0 cg 2 x
o 13-UNDER CARRIAGE 10 1. 2 FIRE ❑ ® U2 C
II c
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 0
POINT OF 8 i 4 C.OM VEH ❑ ® u1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 5 1:_ C
FIRST CONTACT 11 7 __5 •(ryes.See Sidebar
Elgin IL 60120 0 1 0 DL44866 IL 2026 I 0 N
IL D 0 5Y2SL65896Z425464 Direct Auto Insurance ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
99 9 Same PAIL001251337 BAG E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 6 02 / F 2 4 C 1 0
m
/ / #OCCS >
71
/ / UI 2 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 /9/ /025 07 37 123
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 C)
2 ❑ 2 43 81 ,91 /025 08 00 ❑PM ®Construct on
R + 3 ❑ ]$I CITATIONS ISSUED El PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
z J ®AM ❑Maintenance U2
o1 ® 11 1 ARREST NAME Hernandez Ramos. Daniel Jose 11-904-C 1560000063 8/ /9/ /025 08 15 ❑pM SLMT
S' N El CITATIONS ISSUED El PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
AM 30
t 2 ElARREST NAME 8/ /9/ /025 07 37 M PM ElUnknown work zone type U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 35
1560-Jones. Bennett 701 10 / 71 /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 -<
} } ' ' tea` r INDICATE NORTH combination):or -I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
-. ti _ (example:shuttle or charter bus):or 0
I / 3. Is desgned to carry 15 or fewer passengers and operated a contract carrier O
I- I- -A i----
} } 1- transporting employees In the course of their employment(example:employee
( transporter-usually a van type vehicle or passenger car):or w
L L.___a____� °tlN2 } } } 4. Is used or designated to transport between 9 and 1passengers,includingthedriver, C
for direct compensation(example:large van used fors specific purose):or
O
} . } _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
Z � placarding(example:placards will be displayed on the vehicle). ;p
—1
i. i _ CARRIER NAME
Not To Scalei. i. ADDRESS0
CITY/STATE/ZIP C)
'B9B0i0i0"" - i. i. i. i. MOTOR CARR.ID 0 Interstate 0 Intrastate 5
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
; _Y_ _-1 - USDOT NO. ILCC NO. m
XI
Source of above z
. ❑ 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
Silver 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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE