HomeMy WebLinkAbout2025-00057311 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X003943085
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ❑5500 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)
0 AMENDED ® B Injury and for Tow Due To Crash YR 2025I 2025-00057311 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
314 S MCLEAN BLVD El In00:26
® ❑ RELATED 0 Y ®N 09 01 2025 ®AM ❑YES ®NO U1
g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
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COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR ®SLOW 1 cn
❑ FT!MI N E S W Kane 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
g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EOUES 0 NW 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 n
0 4 !
yr NAME(LAST,FIRST,M) Lopez Chili.Alexander Dodge Challenger 2014 00-NONE
13-UNDER CARRIAGE
,, •
12tl)DUE TO CRASH ® ❑
101 •�. 2 FIRE ❑ al
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 0 m
M 2 SY4 ❑Y ®SNEM❑UNK VEH. 0 AT CRASH 0 IN ENGAGED 99-UNKNOWN 9 76•TOP 3 *Detraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S_i L S ii,4 COM VEH El Ea 1 0
F. FIRST CONTACT 1 7_;-_;__5 *Irves.See Sidebar U1
V Z South Elgin IL 60177 0 1 0 FS59152 IL 2026 REAR
TELEPHONE
IL D 0 2C3CDYAG6EH258199 Kemper ❑v ign4 U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Lopez Hernandez.Gabriel 12RA000084482 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 XI
g DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑I uv 0 Ncv ❑Dv
!1 9$6 Volkswagen Jetta 2021 00-NONE 10' 12 (,�2 FIRE DUE OCRASH 0 ® U2 2 C
o 13-UNDER CARRIAGE
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9:1,6_Top
3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN 1,:,_ •Distraction Value 0
POINT OF 8 , COM VEH ❑ ® CO
Ut
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR S
FIRST CONTACT 7 Q _,�_5 •IfYes,See Sidebar
Aurora IL 60504 0 1 0 ER94509 IL 2026 I 0 C
IL D 0 3VWC57BU5MM045782 State Farm ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 2908172SFP13 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 148
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 5 09/01 l2025 00 26 ®❑PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
o"
2 0 08 99 , , ❑PM 0 Construction *
R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM 0 Maintenance U2
-a, ARREST NAME Lopez Chili.Alexander 11-501-A-1 747550 , ! El PM SLMT
o U 1 ® 11 5 CITATIONS ISSUED 0 PENDINGTIME ❑Utility
o NSECTION CITATION NO. ROADCLEARANCE AM
t 2 El ARREST NAME Lopez Chili.Alexander 11-501-A-2 747549 , , DI PM 0 Unknown work zone type U 05
1
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM ❑Y 05
1515-BellEck.Stacy 602 331-Ziegler 10 ,01 ,2025 09 00 ❑PM Workers present? ®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 -<
c ` --I -' r INDICATE NORTH combination):or -I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ } (example:shuttle or charter bus):or
X
L I- --I--•--; '� - transporting mployeened to slIn the course passengers5 or fewer thir emplod yment example:employeener X
transporter-usually a van type vehicle or passenger car):or w
L C
}-----}----; - } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver. N
• for direct compensation(example:large van used for specific purpose):or 0
' L____a____. 41\ t i i 5. Is any vehicle used to transport anyhazardous material(HAZMAT)thatrequires
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placarding(example:placards will be displayed on the vehicle). ;p
I , D
;, CARRIER NAME Z
N.P. ADDRESS
Not To S oio D
C)
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
I r ❑ Not in Comm./Govt. 0 Not in Comm./Other
--- --1 - USDOT NO. ILCC NO. m
XI
Source of above z
. • m
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
Blue Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
_Mies/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE