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HomeMy WebLinkAbout2025-00055388 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 011011001 I0fl INN ft l DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003934593 u, 9 U2 1 1 1 u, 2 U2 1 U199 u2 1 U,99 U2 1 1 9 U1 1 U221 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW ' Elgin Police Department ONE PERSON'S 1215501-$1.500 ®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 202512025-00055388 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m 800 N STATE ST El In 02:05 ® ❑ RELATED 0 Y ®N 08 24 2025 DAM ❑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 ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I El AT RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Q83 DRIVER O PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 1 n / ! FOR DAMAGEDAREA(S) FROPtf TOWED U1 O Unknown.O. Unknown Unknown 00-NONE „ 12 , DUE TOCRASH ❑ EN NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 10 IE 1 ! 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 1 r<r1 SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 9 4 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN = $ 4 COM VEH 0 ZgJ r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _,I[a !i,_ 1 0 I— 0 9 0 FIRST CONTACT 99 7_; _5 *IIYes.See Sidebar U1 REAR 2 Z ' E TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1) unI— known ❑Y ❑N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same unknown 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused 0 Y ® N 99 0 DRIVER X. PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 NMV 0 NCv 0 DV yr Honda Accord 2025 00-NONE ®1 z 1.-_, DUE TO CRASH ❑ !1 2 73 o _ 13-UNDERCARRIAGE 9I ©Ic 2 FIRE 0 ® U2 C c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 ® SPDR 0 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 9 a ❑Y El 0 UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value POINT OF 8 '4 Ut N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR �L'`_ COM VEH ❑ ® CO FIRST CONTACT 11 7 _, _5 ••(ryes.See Sidebar H FF20560 IL 2025 RE 0 N M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 1 HGCY2F57SA034522 AllState 0 V ®N RDEF X EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 HUERTA. PAULA 811733482 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME))(ADDRESS))(TELEPHONE) (EMS) (HOSPITAL) 0 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 18 5 08,24 /2025 02 05 ®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 2 0 99 99 N 3 0 0 CITATIONS ISSUED 0 PENDING + ❑PM• ❑Construction SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 3 z —a, ARREST NAME / / ID PM ' 1 ® 1 1 5 ❑CITATIONS ISSUED ❑PENDING SLMT o u SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utilit y r 2 El ARREST NAME 08 t 24 l2025 02 19 ®PM El Unknown work zone type U1 0 AM 1 O x T n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ID ❑AM Workers present? ❑Y 10 1528-Rivera. Kevin 501 - r ! ❑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 INDICATE NORTH combination):or .Z-1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C x (example:shuttle or charter bus):or 0 X L -Jr- 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O } } } transportingemployees In the course of their employment annm+a '•1°a" transporter- a van vehicle or (example:employee w Po usually type passenger car):or � L L.___a____� 4. Is used ordesi natedtotrans transport passengers,includingN } } } g po the driver, for direct compensation(example:large van used for specific purpose):or 'OD L -a-___� I L 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires / m pWcartling(example:placards will be displayed on the vehicle). ;p D CARRIER NAME Z ADDRESS O -'"r"._ n• CITY/STATE/ZIP 0 MOTOR CARR.ID 0 Interstate 0 Intrastate 1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other ;_...Y._._.; - USDOT NO. ILCC NO. rn XI Source of above Z 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 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Gray u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 9 TOWED BY/TO: _ . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO: DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE