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HomeMy WebLinkAbout2025-00056353 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Df 2 Sheets lUI III H IIIl DIII 01100101111111100111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003945887 u, 1 U2 1 1 1 U, 2 U2 U, 1 1_12 U, 1 U2 1 1 9 U1 1 U221 *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 ❑NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash 0 AMENDED YR 202512025-00056353 VEHT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 m870 LARKIN AVE Elgin08:50 ® ❑ RELATED ❑Y ®N 08 28 2025 ®AM ID YES El NO U1 -< _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 cn ❑ FT/MI NESW Kane HIT&RUN ❑V ® N WITH VEHICLESOT, INVLD ❑ STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS O Q83 DRIVER O PARKED O DRIVERLESS 0 PED CI PEDAL 0 EDUES 0 NOV 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n 0 9 ! yr 13-UNDER CARRIAGE ©,I :: FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® 0 U2 2 m F 2 4 ❑Y ® n 15-OTHER SYSTEM ❑UNK VEH. AT CRASH D 99-UNKNOWN 9 16•TOP 3 ,Distraction Value 5 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, i�6 �i COM VEH 0 El 2 O H ST CHARLES IL 60174-2725 0 1 0 FIRST CONTACT 1 T : __s Yes.See Sidebar u1 Z DZ93690 IL 2026 E TELEPHONE IL D 2G NALCEKXF1157983 State Farm ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Carreto Acosta.Victorrian K065616-001-13A 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ® N 2 XI 0 DRIVER X. PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 NMv 0 NOV 0 DV yr Kia Motors Cot portage 2012 00-NONE 11_. t2 _, DUE TO CRASH rg ❑ 1 0 13-UNDER CARRIAGE I 2 FIRE 0 El U2 C c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED a SYSTEM IN 0 ENGAGED 0 15-OTHER 016•TOP 3 ❑ El SPDR n ❑Y ®N DUNK VEH. AT CRASH 99-UNKNOWN `Oistraellon Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF O 14 COM VEH ❑ ® Ut CO F,,, FIRST CONTACT 7 Q � .s •It Yes,See Sidebar C FH28857 IL 2026 I 0 Si) M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 KNDPC3A23C7213303 Integon Casualty ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Favia.Santina. M. 2028756676 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 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 18 1 08,28 l2025 08 54 ®❑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 0 2 ❑ 20 41 / ) ❑PM ❑Construction * R8 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 o ® 11 3 ARREST NAME Carreto Duran. Kimberly. P. 11-709-A 340000149 / ! El PM SLMT o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility 30 t 2 ❑ ARREST NAME AM 7 1 r ❑❑PM ❑Unknown work zone type U1 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30 340-Phillips. Kathryn 600 10 , 14,2025 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••--, , F A CMV is defined as any motor vehicle used to transport passengers or property and: Z 01. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< ` ` -'- ' INDICATE NORTH comb natlon)or Not Saes i BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C l } (example:shuttle or charter bus):or X v 4 3. Is desgned to carry 15 or fewer passengers and operated a contract carrier O } } } transporting employees In the course of their employment(example:employee transporter-usually a van type vehicle or passenger car):or w L i.-----}----; al uric iI. } } } C •4. Is used or designated to transport between 9 and 15 passengers,including the driver, w for direct compensation(example:large van used for specific purpose):or L L--_-a-.... - t i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires •U placarding(example:placards will be displayed on the vehicle). XI Itt � CARRIER NAME Z __ ADDRESS O C) CITY/STATEJZIP L i• : .i -------\ MOTOR CARR.ID 0 Interstate ❑ Intrastate I I T I { ❑ Not in Comm./Govt. Not in Comm./Other ❑ 0 --- --1 USDOT NO. ILCC NO. m XI Source of above z . 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 M 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 Red Gray u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO. Arties/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE