HomeMy WebLinkAbout2025-00058180 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 011011001 I0H
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 3
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and f or Tow Due To Crash YR 2025I 2025-000581 s0 VEHT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 mN RANDALL RD El In11:24
® ❑ RELATED ' V 0 N 09 04 2025 ®AM ❑YES ®NO U1 -<
_ _ g PRIVATE mo !day/yr ❑PM FLOW CONDITION m
FT!MI N E S W 190 EB EXPY COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR IR SLOW 3 Cl)
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0
g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 Mlles 0 uuv 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
0 3 /
yr Q -
13-UNDER CARRIAGE 16 i 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ ga U2 4 rn
M 2 4 SY❑Y ®SNE❑UNK VEH. 0 AT CRAS IN H 0 99-UNKNOWN 9 76•TOP 3 `Distraction Value ALGN 2
T. CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _IL 6 I,.4 COM VEH 0 181 1 C)
~ Belvidere I L 61008 0 1 FIRST CONTACT 12 Y. _-5 *eves.See Sidebar U1
Z3926695B IL 2026
TELEPHONE
IL D 5LTPW18576FJ03423 Bristol West Ins.Co ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same G01447285602 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Refused ❑Y ® N 2 c
g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMv 0 Ncv 0 DV
!1 9 yf 2 Chrysler Pacifica 2019 00-NONE ,,"j t2..-_, DUETO CRASH ❑ 2 x
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13-UNDERCARRIAGE 10;1 2 FIRE ❑ ® U2 C
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F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP
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❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istraellon Value POINT OF 0
s 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 5 l:' U1
COM VEH ❑ ® CO
FIRST CONTACT 6 Y�; ,__5 •If Yes,See Sidebar
= Algonquin IL 60102 0 1 BF87771 IL 2026 REAR0 Si)
IL D 2C4RC1EG6KR589798 Geico Secure ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 6079-68-75-02 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 09/04 /2025 11 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 �
0 2 03 28 / / 0 PM 0 Construction *
R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM 0 Maintenance U2
o1 ® 11 1 ARREST NAME Gutierrez-Navarrete. Narciso 11-710-A 327003233W / ! El PM SLMT
o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility
45
t 2 ❑ ARREST NAME AM
7 / / pM 0 Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ - ❑AM Workers present? ❑Y 45
327-Hromadka.Scott 901 / / ❑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 -<
` ` -' -' r INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} - i. e. r ,. (example:shuttle or charter bus):or
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i 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O
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I 1 transporting employees in the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or w
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-- I i - } }} 4. Is used or designated to transport between 9 and 15 passengers,including the driver, N
oarfor direct compensation(example:large van used for specific purpose):or' O
___� t l. L 1 L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires L L `
placarding(example:placards will be displayed on the vehicle). D
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A
CARRIER NAME Z
ADDRESS 'n
Not To Scale j w
CITY/STATE/ZIP o
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
--- --1 - USDOT NO. ILCC NO. m
XI
Source of above z
. -I
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
Maroon Gray
u 1 TOWED - TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO:
_ 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