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HomeMy WebLinkAbout2025-00056499 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 I011011001 I0fl I II III II 110 DRAC TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X003939392 u, 1 U21 3 4 1 U1 1 U2 1 U, 1 1_12 1 u1 4 U2 1 1 11 U1 11 U2 11 *P 0119 INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash ❑AMENDED YR 202512025-00056499 VEHT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 mKI M BALL ST El In06:18 ® ❑ RELATED ❑Y ®N 08 28 2025 ❑AM ❑YES ®NO U1 -< _ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION m FT!MI N E S W N STATE ST COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 1 (n ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ 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 NV., 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 5 0 Q Nevarez. Eduwiges Honda CRV 2003 00-NONE „ • 12 , DUE TOCRASH ® ❑ NAME(LAST,FIRST,M) g mo yr 13-UNDER CARRIAGE 101 2 FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 5 M M 2 4 SYTM❑Y ®SNE❑UNK VEH. 0 AT CRASH 99-UUNKNOWN THER9 16•TOP 3 ,Distraction Value 9 ALGN X. r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s it a ii COM VEH ❑ ga 2 C) ~ ELGIN I N I L 60123 0 1 0 FIRST CONTACT 6 ki::LQ_OS •II Yes.see Sidebar U1 0 Z V72999 IL 2026 E TELEPHONE IL D 0 SHSRD78483U117397 All State ❑Y ®N U2 13 . m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same 802192199 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER > Refused 0 Y ® N 2 XI m x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 lily 0 Ncv 0 Dv yr Q 2 !� �1 0 13-UNDER CARRIAGE 10 j ©( 2 FIRE 0 ® 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 `0istrac) n Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 1 S i COM VEH ❑ ® ut CO FIRST CONTACT 1 O7 ,�=Q)OS •IfYes.SeeSidebar ELGIN IL 60123 0 1 0 FE49661 IL 2026aR Z IL D 0 3N1AB7AP2KY347411 Root Ins ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same JKH3Z2 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)1(TELEPHONE) (EMS) (HOSPITAL) 1 3 12 / F 2 3 0 1 0 m / / #OCCS D / / UI 2 m / / 1 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 1 08,28 /2025 06 18 ®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 0 10 28 1 1 ❑PM ❑Construction >F Z3 0 I!!I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 o 1 El 11 1 ARREST NAME Nevarez. Eduwiges 11-601 S1519-000395 ! ! ❑PM SLMT ISI CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM• • 0 Utility t 2 El ARREST NAME Franco. David. I. 3-707 S1519-000396 08128 /2025 07 00 0 PM El Unknown work zone type U1 30 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30 1519-Bae2 a.Guadalupe 601 10 1 07,2025 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 -< ` ` --I -' r INDICATE NORTH combination):or —I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } } r 1i. e. r r (example:shuttle or charter bus):or 0 l 3. Is designed to carry15 or fewer passengers and operated a contract carrier O L }____A____� i rowerva - y } } } transportingemployeesinthecourseeoftheirem t r transporte -usuall a van type vehicle or passenger car)(orxample:employeew --- - _-- urxr x- 4. Is used or designated to transport between 9 and 15 passengers,including N i. }--- ----+ 1 a - } } } C g po pafic p rs,includi the driver, —-uar,-uroT3------ for direct compensation(example:large van used for specific purpose):or O __ ___ - •- - _ t i. i L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m placarding(example:placards will be displayed on the vehicle). XI -- 1 CARRIER NAME I ® _ ADDRESS 'n I Notlbanb J V) I wamrra 0 CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate 0 Intrastate 1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other �I. ------1 - USDOT NO. ILCC NO. rn XI Source of above z . If Yes,Name on placard 0 4 digit UN NO. 1 digit Hazard class No. XI XI 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?El❑ Yes II 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'; ❑Yes 0 No 2 TRAILER VIM 1 m co LOCAL USE ONLY TRAILER VIN 2 m v TRAILER WIDTH(S) 0-96" 97-102" >102' T TRAILER 1 0 0 0 Z TRAILER 2 ❑ 0 ❑ O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Silver Black u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. _Arties/Owners Residence . 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