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HomeMy WebLinkAbout2025-00058348 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I011011001 ll fl III IOU 110 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003950041 u, 1 U211 2 4 1 u, 2 U2 1 u,99 u2 1 u, 1 U2 1 1 15 u, 1 U2 1 *P 0119 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 El$501-$1.500 ®ON SCENE 14 VEHICLE/PROPERTY El OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash 0 AMENDED YR 2025I 2025-00058348 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1 ® ❑ RELATED ®Y 0 N 09 05 2025 ®AM ❑YES ®No U1 MAY ST Elgin 07:42 g PRIVATE mo /day/yr ❑PM FLOW CONDITION m FT!MI N E S W COOKANE AVE COUNTY PROPERTY ❑Y 2�1 N DOORING Ely #OF MOTOR 0 SLOW 1 0)0 Cook HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0 Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEOAL 0 EWES 0 NIAV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C) 0 9 / yr 13-UNDER CARRIAGE ©,I �:: FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 O m F 2 5 SYTM❑Y OS NE❑UNK VEH. O AT CRASH 0 15-99-UNKNOWN THER9 16•TOP 3 `Distraction Value 9 ALGN X. r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, ii_6 I,.4 COM VEH 0 El 1 0 I . ELGIN I L 60120 B 1 0 FIRST CONTACT 12 7 ; _5 *II Yes.See Sidebar U1 Z FB71044 IL 2026 REAR TELEPHONE IL D 0 1 G 1 PA5SGOD7230064 Progressive ❑v ®N U2 I' 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Elgin Fire 99 9 Aguiar. Daniel 860590227 1 o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER r 2 eu N DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES 0 MAV 0 i v 0 Dv /1 9 8 3 Nissan Altima 2016 00-NONE „ `'12' , DUE TO CRASH rg ❑ 2 x o - ®13-UNDER CARRIAGE FIRE ❑ ® U2 c F 2 5 SYSTEM IN 0 ENGAGED 0 15-OTHER O9 16-TOP 3 X ❑Y gi N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistrac on Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i '-4 COM VEH ❑ ® U1 CO F,,, FIRST CONTACT 1 O Y��_,-=5 •(ryes,See Sidebar C ELGIN IL 60120 B 1 0 AT39881 IL 2025 I Si)0 M IL D 0 1 N4AL3AP8GC123908 Country Preferred ®Y ❑N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 X Elgin Fire 99 9 Portillo Hernandez.Carlos.A. PO10197586 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) 2 3 01 / U1 1 D / / 2 O U EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur 0 Y U2 Z N 1 El 11 4 91 //2 /25 07 42 ❑PM in a Work Zone? ®N DIRP D co 1 t PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 7 C) T o", 2 ❑ 2 18 / / ❑PM, ❑Construction Z3 ❑ xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5 a1 ® 11 4 ARREST NAME Negron. Makayla. M. 11-904-B 1540-334 / / El PM SLMT o N 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility AM 25 r 2 ElARREST NAME 91 //2 /25 08 20 M PM ElUnknown work zone type u, 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 25 1540-Allah. Muhammad 401 10 / 14/2025 01 30 El NI ®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 i- `----'-----4. I I t INDICATE NORTH combination):or more thanpounds(example:truck or truck/trailer 1. Hasa rating10,000 r.ltr. I BY ARROW 2 Is used or designed to transport more than 15 C g sp passengers including the driver r r r (example:shuttle or charter bus):or 0 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O A } } } transporting employees in the course of their employment(example:employee enger car):or X L -----}----+ —--wpm - } } } •4 transporter osed or des gnated to transport betweelly a van type vehicle or n 9 and 1 passengers,including the driver, �iCO 4 Is (C/t unn��y �® for direct compensation(example:large van used for specific purose):or O L It1 ,-vntl2 t i iany t 5. Is any vehicle used to transport hazardous material(HAZMAT)that requires m placarding(example:placards will be displayed on the vehicle). > 43Y CARRIER NAME Z I N - ADDRESS T.to i _ Not To Scale I n CITY/STATE/ZIP 0 MOTOR CARR.ID 0 Interstate 0 Intrastate I I I I ��va ❑ Not in Comm./Govt. ❑ Not in Comm./Other 0 r _Y____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. 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 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 to LOCAL USE ONLY TRAILER VIN 2 m 0 TRAILER WIDTH(S) 0-96" 97-102" >102' -n TRAILER 1 0 0 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w White White 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 DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE