Loading...
HomeMy WebLinkAbout2025-00056153 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 11111111 IIloll 1111111 1111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XO03935405 u, 1 U21 2 4 1 U, 3 U2 1 U, 1 1_12 1 U, 1 U2 1 1 15 U1 1 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 14 VEHICLE/PROPERTY El OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash El AMENDED YR 202512025-00056153 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn CONGDON AVE El 11:55 ® ❑ RELATED ®Y 0 N 08 27 2025 ®AM YES ®NO U1 -< _ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION III FT l MI N E S W PRESTON AVE COUNTY PROPERTY ❑Y ® N DOORING ICIy #OF MOTOR 0 SLOW 15 u) ❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 —I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0 icy ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) y N O 0 Ptf TOWED U1 Q Acosta Romo. Mariana Honda Fit 2017 00-NONE „ t2 , OUETOCRASH ® ❑ NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 10 . 2 FIRE ❑ al � STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 0 M F 2 4 ❑Y ®SNE❑UNK VEH. O SYTM AT CRASH 0 99-U 15- NKNOWN THER9 16•TOP® ,Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ it 6 jl y COM VEH 0 )g! 1 C) .V. Z Chicago I L 60639 0 1 0 EX89490 IL 2026 FIRST CONTACT 4 7_:REAR -O =Ir ves.See Sidebar U1 c TELEPHONE NA Other 3HGGK5G77HM701637 None ❑Y ❑N U2 I' in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same None 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused 0 Y ® N 2 73 N DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑i uv 0 i v ❑DV /1 9 5 7 O Honda CRV 2022 00-NONE al z j.-_, DUE TO CRASH ❑ ® 18 73 0r ® C) 13-UNDER CARRIAGE 6 I ©Ic 2 FIRE 0 ® U2 C c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 X ❑Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN `0istraclonValue 0 POINT OF 8 i1�i 4 COM VEH ❑ ® U1 W N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6 FIRST CONTACT 11 7 -6 •If Yes,See Sidebar Z ST CHARLES IL 60175 0 1 0 FH95819 IL 2026 0 N D IL D 0 7FARW2H93NE004674 State Farm ❑Y ®N RDEF .73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same 2330976SFP13 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 < Refused RESPONDER U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 2 6 08 / F 2 4 B 1 0 m / / #OCCS D / / U1 1 D / / 2 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 El 11 4 8/ ,71 /025 11 55 ®❑pM in a Work Zone? NJ DIRP D co 1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM 0 T 23 2 If YES check one below: U1 5 C) 2 ❑ / / ❑PM ❑Construction Z3 ❑ Igi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 3 -a, ARREST NAME Acosta Rom. Mariana 3-707 369002266 / / ID PM SLMT o u 1 ® 11 4 CITATIONS ISSUED 0 PENDINGTIME ' ❑Utility o NSECTION CITATION NO. ROADCLEARANCE 0 AM 30 t 2 El ARREST NAME Acosta Rom. Mariana 11-904-B 369002267 / / pM ElUnknown work zone type U1 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 35 369-Varga,John 201 9/ , 3/ /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 -< i- }-- -'-- --' I - INDICATE NORTH combination):or 01%11 BY ARROW2 Is used or designed to transport more than 15 passengers including the driverCIlbj - (example:shuttle or charter bus):or C) } A i Not to scare 1 3. Is designed to car 15 otr fewer passengers and operated a contract carrier O } } } transporting employees In the coursee of their employment(example:employee X transporter-usually a van type vehicle or passenger car):or L L.___a__ 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver, I crww .�nw. Pe ( P 9 Pe or O L L--_-a-.... — — /.\tom — — — - t i } I 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m a placarding(example:placards will be isplayed on the vehicle). ri [Ili CARRIER NAME Z v I _ __ ADDRESS 'O r�.m.rt rn CCITY/STATE/ZIPOC) MOTOR CARR.ID 0 Interstate ❑ Intrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other i— --- --1 USDOT NO. ILCC NO. m XI Source of above z . Were HAZMAT placards on vehicle? 0 Yes 0 No = If Yes,Name on placard O 4 digit UN NO. 1 digit Hazard class No. Xl Xl Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z own tank)? 0 Yes 0 No 0 Unknown Did HAZMAT Regulations violation contribute to the crash? r ❑ 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 White Blue u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 2 TOWED BY/TO. _Mies/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 DUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO: DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE