HomeMy WebLinkAbout2025-00054416 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 011011001 I0fl
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003934487-
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY [g]OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 2025I 2025-00054416 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 :l
® ❑ RELATED ®Y 0 N 08 20 2025 ❑AM ❑YES N NO U1 -<
HILL AVE Elgin05:38
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FTlMI N E S W JEFFERSON AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ Kane HIT&RUN ❑V ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 —I
lgi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑NIAV ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C)
FOR DAMAGEDAREA(S) Ii20 1T TOWED U1 Q
Gonzalez. Ernesto 1 1 /
yr 13-UNDER CARRIAGE 101 2 FIRE 0 N
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 0 m
M 2 SYTHER
4 ❑Y NSNE❑UNK VEH. 0 AT CRASH IN ENGAGED 0 99-UNKNOWN 9 76-TOP 3 `Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 i�6 �i COM VEH 0 j$J 1 0
F.
Lombard I L 60148 0 1 0 FIRST CONTACT 1 7 ; __5 *II Yes.See&debar U1
ZCW86101 I L 2026 REAR
TELEPHONE
IL D 0 1 G N FK13548R188473 Progressive ❑Y Il N U2 I—
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 99 9 Same 980815793 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
t RESPONDER >
g DRIVER 0 PARKED ❑DRIVERLESS ❑ FED ❑PEDAL 0 EWES ❑MAV 0 NCv ❑DV
!1 9 9 4 Honda H R-V 2025 00-NONE O,' t2 "_, DUE TO CRASH rg ❑ 2 x
0 Yr 13-UNDER CARRIAGE 10 I 2 FIRE 0 ® U2 C
c
F 2 8 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value 9 g
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8
-iI�1:, 4 COM VEH ❑ N U1 CO
FIRST CONTACT 11 7 -5 •If Yes.See Sidebar
Z ELGIN IL 60120 B 1 0 FE25655 IL 2026 I g C
IL D 0 3CZRZ2H78SM763159 Allstate ❑Y ®N RDEF .XJ
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 979354553 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 4 81 ,01 l025 05 38 ®AM in a Work Zone? NCI N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
2 0 2 99 81 /01 /025 05 40 ®PM 0 Construction
*
R O ❑ ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
J ❑AM ❑Maintenance U2
4 1El 11 4 ARREST NAME Gonzalez. Ernesto 11-1204-B 1530000469 81 /01 /025 05 43 Igi pM SLMT
o Nu ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' ❑Utility
0 AM
t 2 0 ARREST NAME 81 /01 /025 05 55 ®PM 0 Unknown work zone type U1 15
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 15
1530-Soto.Oscar 201 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
nR ADDITIONAL UNITS FORMS.
r ----r••--, , N ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
II 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
i- }-----I-----' r - r INDICATE NORTH combination):or -I
Not To Scale j BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
•
- } (example:shuttle or charter bus):or
3. Is desgned to carry 15 or fewer passengers and operated by a contract carrier 0
J II. } } transporting employees in the course of their employment(example:employee73
transporter-usually a van type vehicle or passenger car):or w
4. Is used or designated to transport between 9 and 15 passengers,including rCjt
} } } g po passen rs,includi the driver,
for direct compensation(example:large van used for specific purpose):or O
' L____a____. _ L i i t 5. Is an vehicle used to transport an hazardous material(HAZMAT)thatrequires
Jefferson?Ave placarding(example:placards will be any
on the vehicle). m
Unit 1 ›
--
CARRIER NAME Z
ADDRESS 0
NI—• I-/� D
rn
r n
, CITY/STATE/ZIP 2
`�'�%t. _ MOTOR CARR.ID ❑ Interstate ❑ Intrastate
I I T I ❑ Not in Comm./Govt. Not in Comm./Other 00
H[I[?Ave 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 No ❑ 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'; 0 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 Black
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
Redmons . 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 VEHICLE CONFIG._CARGO BODY TYPE LOAD TYPE