HomeMy WebLinkAbout2025-00054450 ILLINOIS TRAFFIC CRASH REPORT Sheet`1 of 2 Sheets 111111111111 111111 I011011001
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT) El B Injury and f or Tow Due To Crash
El AMENDED
YR 2025I 2025-00054450 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 -n
® ❑ RELATED ®Y 0 N 08 20 2025 ❑AM ❑YES ®NO U1
SUMAC LN Elgin09:03
_ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FTlMI N E S W BODE RD COUNTY PROPERTY ❑Y 1�1 N DOORING ❑y #OF MOTOR ❑SLOW 17 (n
❑ Cook HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUES 0 uuv 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
FOR DAMAGED AREA(S) FROPtf TOWED U1 Q
NAME(LAST,FIRST,M) GUTIERREZ.VICTOR. M. 0 mo /5
13-UNDER CARRIAGE ,a i ' 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
M 1 SY4 ❑Y ®SNE❑UNK VEH. O AT CRAS IN H O 99-UNKNOWN 9 16•TIDP 3 `Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s_iL I,.4 COM VEH 0 18! 1 0
~ ELGIN I L 60120 0 1 0 FIRST CONTACT 12 7_: _5 *II Yes.See Sidebar U1
Z 1509224 IL 2025 REAR
TELEPHONE
IL D 0 5TDZK23C57SO43890 Allstate ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 975867621 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y El 2 ou
❑ DRIVER ❑ PARKED 0 DRIVERLESS 0 PED '}�. PEDAL 0 EWES 0 IIIAV 0 kKV 0 DV
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0 13-UNDER CARRIAGE ., FIRE ID El U2
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M 5 3 SYSTEM IN ENGAGED 15-OTHER 9 6 TOPO3 * 0 X
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN Oistraellon Value
NI CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POFIRSNT OF T CONTACT 14 Q_�LO r
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ELGIN IL 60120 A 2 8REAR
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IL D 0 None ❑Y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
1 99 6 Same None BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Provena St.Joseph RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
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/ / 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 13 4 08,20 l2025 09 03 ®AM 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 C)
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2 28 99 ! ! 0 PM• ❑Construction *
Z 3 ❑ Ii CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM ❑Maintenance U2
a GUTIERREZ.VICTOR. M. 11-601-Ax 455-437 / ! PM '
-, ® 13 4 ARREST NAME ❑
o u ig!CITATIONS ISSUED 0 PENDING UtilitySLMT
o N SECTION CITATION NO. ROAD CLEARANCE TIME AM• 0
t 2 0 ARREST NAME G UTI ERREZ.VICTOR. M. 11-402-A 455-438 08/20 /2025 09 51 ®PM ❑Unknown work zone type u1 25
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 25
455-Hallac.Gabriel 302 09 / 16,2025 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 -<
` ` --1 -' r INDICATE NORTH combination):or .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
j. - } (example:shuttle or charter bus):or
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3. Is d fined t carry 15 or fewer passengers and operated a contract carrier O
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j I (... ; } } } transporting employees In the courses of their employment(example:employee
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L L.___a__ 4alsuosedordestlnatedto transport between9 and r15r) ssen rs,indudingthedrrver,
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% } } } • for direct compensation(examp large van used for specific purpose):or
L L--_-a-.... - l. i. I 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires`4� N placarding(example:placards will be displayed on the vehicle). XI
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CARRIER NAME Z
ADDRESSi.
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0
Not To Scats >
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CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate ❑ Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
-"------"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
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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
Silver
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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/T6
DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE