HomeMy WebLinkAbout2025-00056518 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 1111 III 11 III1II IIIIII 0110010 11111 III IlU 11111
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003943351
u, 1 U2 2 4 1 U, 3 U2 1 U, 1 1_12 U, 1 U2 1 1 9 U1 1 U222 *P 0119*
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 1
VEHICLE/PROPERTY ®OVER$1,500
El NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 2025512025-00056518 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED ®Y 0 N 08 28 2025 ❑AM ❑YES ®NO U1 -<
KEEP AVE Elgin08:01
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT l MI N E S W PRESTON AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
El 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 Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FOR DAMAGEDAREA(S) FROM TOWED U1 Q
NAME(LAST,FIRST,M) y mo
1 9 9 7 Honda Accord 2016 00-NONE ,, • 12 , DUE TO CRASH ❑ EN
13-UNDER CARRIAGE FIRE ❑ IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED 0 Ea U2 2 m
M 2 SY4 ❑Y ®SNE❑UNK VEH. O AT CRASM IN H O 99-UNKNOWN 9 76•TOP 3 `Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $_iL 6 j- 4 COM VEH 0 E! 1 0
~ ELGIN IL 60120 0 1 0 FIRST CONTACT 1 7_; __5 *IIYes.See Sidebar U1
Z 7RXU836 CA 2025 REAR
TELEPHONE
IL D 1 HGCR2F73GA147695 Aspire ❑Y ®N U2 1-
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same G PSV-00721053-00 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y ❑ N 2 ou
❑ DRIVER X. PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 iiuy 0 i v 0 Dv
yr 13-UNDER CARRIAGE 1U 1 t2 ;,_2 FIRE 0 ® U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN 0 ENGAGED 0 15-OTHER O9 16.70P 3 0 ® SPDR n
❑Y ®N DUNK VEH. AT CRASH 99-UNKNOWN *Oistraglon Value 9 0 -
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 0 1 6 4 COM VEH 0 ® U1 CO
F,,, FIRST CONTACT 7 Q i, .5 •It Yes.See Sidebar C
EG72081 IL 2012 I 0 (p
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
1 9XFB2F52CE038876 Kemper ❑V ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
Soriano Sanchez, Eugenio 1 2RA00004341 6 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 18 1 08,28 r2025 08 01 ®PM in a Work Zone? ®N DIRP co
I I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
0 2 0 23 28 , ) 0 PM 0 Construction *
4
R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. E1�45 ARRIVED TIME 3
❑AM 0 Maintenance U2
-a, ARREST NAME Arias Revilla, Dayan,A. 11-1204-B 1534000319 r r El PM SLMT
o U 1 ® 11 1 CITATIONS ISSUED 0 PENDINGTIME • 0 Utility
o NSECTION CITATION NO. ROADCLEARANCE 0 AM 30
t 2 0 ARREST NAME Arias Revilla, Dayan,A. 11-601-Ax 1534000320 r r PM 0 Unknown work zone type U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 30
1 534-Santiago.Jorge 201 09 , 16,2025 01 30 ®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 unitshave been moved prior to officer's arrival.
IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A
ADDITIONAL UNITS FORMS.
r ----r••--, , 1 abn ^� ; A CMV is defined as any motor vehicle used to transport passengers or property and: D
;` z
.�
Keep?A _ 1. Has a
combination):eighht t rating more than 10,000 pounds{e le xamp :truck or truckrtrailer -Ir }----------, 661 ` INDICATE
NORTH C
Keep ARROW 2 Is used or designed to transport more than 15 passengers including the driver
AveI■ - r r r (example:shuttle or charter bus):or 0
of
a 3. Is designed to carry 15 or fewer passengers and operated a contract carrier 0
I- <.__-A----1 U fl,t } } } } transportingemployees in the course of their employment(example:employee X
till
transportr-usually a van type vehicle or passenger car): r w
L L.___a.. 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including
} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Preston?Ave Pe ( P 9 Pe or o
L i t i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). ;p
Z
li
CARRIER NAME Z
ADDRESS 0
® D
Keep?Ave
CITY/STATEJZIP
Not To Scale Ii. i. i. i. MOTOR CARR.ID 0 Interstate 0 Intrastate
l I . l ❑ Not in Comm./Govt. 0 Not in Comm./Other
; _Y_ _-1 - USDOT NO. ILCC NO. m
XI
Source of above z
. ❑ Yes 0 No 0 Unknown M
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
White 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 DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Other/Unknown VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE