HomeMy WebLinkAbout2025-00052569 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 1011011001 I0
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003953D86
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑5501-51,500 ®ON SCENE 3
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 2025I 2O25-00052569 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �l
RT20 EB El In10:00
® ❑ RELATED 0 Y ®N 08 13 2025 ®AM ❑YES ®NO U1 —<
_ _ g PRIVATE mo !day/yr ID PM FLOW CONDITION MFT!MI N E S W S STATE ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 NUV 0 NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
1 0 FOR DAMAGEDAREA(S) FROt tf TOWED U1 Q
NAME(LAST,FIRST.M) VIIlagomeZ-Hernandez.Sarahid mo Ford Escape2013 00-NONE! ! yr 11. 12
Q DUE TO CRASH 0 E
13-UNDER CARRIAGE ! FIRE 0IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 1U O DISTRACTED 0 0U2 2 171
F 2 SYTM 4 ❑Y ®SNE DUNK VEH. O AT CRASH 0 15-99-UUNKNOWN THER9 16•TOP 3 *Distraction Value 9 ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s_iL 6 4 COM VEH 0 j$J 1 0
F.
ELGIN I N I L 60123 0 1 0 FIRST CONTACT 00 7_; __5 *II sees.See Sidebar U1
Z CZ8391 IL 2025 REAR
TELEPHONE
IL D 0 1 FMCU9GX9DUC32437 Accurate Auto ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same I LAA1094243-00 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Refused ❑Y ❑ N 2 0
x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 m,lv 0 Ncv 0 Dv
Yr - 13-UNDER CARRIAGE FIRE 0 ® U2
II
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER O9 16-TOP 3 X
❑Y El N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 4
POINT OF 8 I COM VEH D ® Ut CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 5 1:_ C
FIRST CONTACT 11 7 _, _5 •IfYes,See Sidebar
Hanover Park IL 60133 0 1 0 EG34081 IL 2025 I 0 Si)
IL D 0 2C3CCABT8G H 175852 Progressive Ins ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Marquez-Zavala, Enrique 989415234 BAC
E
HOSPITAL(TAKEN TO) INCIDENT RESPONDER IF'Y' OWNER STREET,CITY,STATE,ZIP 996 ARefused ❑Y ❑N U1 =
(UNIT) (SEAT) (D08) (SEX) {SAFT) (AIR) OHM (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
2 3 10 / F 2 4 0 1 0
m
/ / #OCCS >
71
/ / U1 1 D
/ / 2 0
E/ MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 08!13 /2025 10 00 ®❑PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
2 ❑ 28 20 ! ! ❑PM ❑Construction *
5 4
R 1 3 0 $I CITATIONS ISSUED PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM ❑Maintenance U2
o1El 11 1 ARREST NAME Villagomez-Hernandez,Sarahid 11-601 254001596 / ! El PM SLMT
o N 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
50
t 2 ARREST NAME AM
7 El ! / ❑❑PM ❑Unknown work zone type U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 50
254-Henke. Robert 700 275-Engelke 09 !09 l2025 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 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
- } (example:shuttle or charter bus):or
X
- ------;----; ® transporting emploned to yees Inthe course of 5 or fewer rye r employmentrs tl operated
(example:employee
a contract der
..u,..n_ •.�. T... .¢.ram._ _ .a_: transporter-usually a van type vehicle or passenger car); r
C
i. <____a____i. 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or 0
' L____a____. •'nk1 ^"-r ••nkL M/ O1her - } } 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires® placarding(example:placards will be displayed on the vehicle). XI
—Unit2 Vnn 2--4.1on2 11 - -- —I
Unit1 Unk2 CARRIER NAME Z
717 8OOl•j _ ADDRESS 0
w
n
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate El Intrastate
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
T.
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes ❑ 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' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Blue Blue
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 DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE