HomeMy WebLinkAbout2025-00054123 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003923721
u, 1 U21 1 4 8 U, 8 U2 9 U, 1 1_12 1 U, 1 U2 1 1 18 U1 12 U223 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S 1:g5501-51,500 ®ON SCENE 2
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
El AMENDED
YR 202512025-00054123 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 -<
SUMMIT ST Elgin02:38
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FTlMI N E S W DUNDEE AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 —I
Igl AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
Oquendo. Eduardo 0 5 /
yr 13-UNDER CARRIAGE 10:) 2 , 2 FIRE ❑ al E
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 4 rn
M 2 SY4 ❑Y ONM❑UNK VEH. O AT CRASH IN O 99-UNKNOWN 9 76•TIDP 3 *Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ iI s 4 COM VEH 0 Ea 1 0
~ ELGIN I L 60120 0 1 0 FIRST CONTACT 12 7 ;1 _5 *Yves.See Sidebar U1
Z 5423113 IL 2025 E
TELEPHONE
IL D 0 1 FMCU9H98DUC47981 Progressive ❑v Il N U2 (TI
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 99567927 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused El ® N 2 0
m �{ DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES O N4v 0 NCv ❑Dv CIRCLE NUMBER(S) U1
1 9 7 Hyundai Accent 2015 00-NONE ,�_-I t2..-_, DUE TO CRASH ❑ C 2
o yr 13-UNDERCARRIAGE ta;l 2 FIRE ❑ ® U2 C
c
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 iII S .,_4 COM VEH ❑ ® Ut W
FIRST CONTACT 6 Y__{_O ._5 ••(ryes.See Sidebar
= ELGIN IL 60120 0 1 0 AB45475 IL 2025 REAR
D
IL D 0 KM HCT4AE907445 Bristol West ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same GO1 48127702 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAF() (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 1 08(19 (2025 02 38 ®PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
o"
2 ❑ 20 99 / ( ❑PM ❑Construction *
R 3 ❑ $I CITATIONS ISSUED El PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM ❑Maintenance U2
o ® 11 1 ARREST NAME Oquendo. Eduardo 11-708 (W)455-436 / ! El PM SLMT
o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility
25
r 2 ARREST NAME AM
7 ( r ❑❑PM 0 Unknown work zone type U1
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OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 455-HallaE.Gabriel 301 391-Jacobucci ( / ❑❑PM Workers present? ®N U2 25
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
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
rmm� - } (example:shuttle or charter bus):or
A I 3. Is designed to carry 15 or fewer passen ers and o rated a contract career O
1 L___, 1.. ......
I. } } } transporting employees In the course of their employment(example:employee
as transporter-usually a van type vehicle or passenger car):orCO
L L.___a____1 e - 4. Is used ordesi natedtotrans rtbetween9and15passengers,includingthedriver. y
�I I — — •— — — — } } } for direct compensation(example:large van used for speific purose):or O
L I-_._-a____-I •/._ i3 - t i i 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires M
-- placarding(example:placards will be displayed on the vehicle).
- -I
CARRIER NAME Z
ADDRESS 0
D
rn
0
Not To Scale ' CITY/STATE/ZIP g
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. rn
XI
Source of above z
❑ 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
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Gray Silver
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE