Loading...
HomeMy WebLinkAbout2025-00060356 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 6 Sheets 01111101111 011011001 011111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003966613 u, 1 U21 2 4 1 u, 5 U2 1 u,99 u2 1 u, 1 U2 1 5 10 u1 4 u2 3 *P 0119 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 1 VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT) El AMENDED ElB Injury and for Tow Due To Crash YR 202512025-00060356 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ® ❑ RELATED ®Y ❑N 09 13 2025 ❑AM ❑YES ®NO U1 -< CHIPPEWA DR Elgin08:35 _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m FTlMI N E S W JEFFERSON AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n ❑ Cook HIT&RUN ®Y ❑ N WITH VEHICLES INVLD ® STOPPED U2 —I lgi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 Qg3 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 4 n FOR DAMAGEDAREA(S) FRO r TOWED U1 Q Orte a Ramirez.Jose. E. 0 1 / yr 13-UNDER CARRIAGE ©i ! FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) EN O 2 DISTRACTED 0 0 U2 4 M M 1 SYTM IN ENGAGE15-OTHER 4 ❑Y ®SNE DUNK VEH. 0 AT CRASHD 0 99-UNKNOWN 9 76•TOP 3 *Distraction Value ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s,;i�6 4 COM VEH 0 j$J 1 0 ~ ELGIN I L 60120 0 1 0 FIRST CONTACT 10 7 ; _5 *Irves.See Sidebar U1 ZET84467 IL 2026 REAR TELEPHONE UNK. 9 3N 1 AB7APXFY348604 No Insurance ®Y ❑N U2 m .5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Cruz.Andre. H. No Insurance 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 ou m �{ DRIVER ❑ PARKED 0 DRIVERLESS ❑ FED 0 PEDAL 0 EWES 0 uv 0 NOV 0 Dv — 13-UNDER CARRIAGE c F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 911,6•TtOP 3 X ❑Y NJN El SYSTEM VEH. AT CRASH 99-UNKNOWN *Oistracton Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF G'i- 6 I,'•. 4 COM VEH ❑ ® U1 CO C FIRST CONTACT 8 Q __,�_5 •Iryes.See Sidebar ELGIN I L 60120 0 1 0 E274161 I L 2025 REAR Si)0 IL D 0 1 HGCR2F56FA050374 Allstate ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X 99 9 Hernandez.Guadencia 966210413 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE:ZIP ui = KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) U2 996 r U1 1 D 1 0 E/ MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 4 09,13 ,2025 08 35 ®pm in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 v 2 28 99 09,13 ,2025 08 35 ®PM ❑Construction <w O 0 gi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 3 ❑AM 0 Maintenance U2 -a, ARREST NAME Ortega Ramirez.Jose. E. 11-601-Ax S1527-000356 / i El PM SLMT 1 ® 11 4 • 0 Utility CITATIONS ISSUED ❑PENDING o u SECTION CITATION NO. ROAD CLEARANCE TIME AM r 2 El ARREST NAME Ortega Ramirez.Jose. E. 3-707 S1527-000357 09 r 13 r2025 08 55 ®PM El Unknown work zone type U1 15 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 15 1527-Juarez.Jorge 201 391-Jacobucci 10 ,28,2025 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 i- i•____r____1 - LR „_. ® _ 1. Hasa r more than pounds(example:truck or truck/trailer 1. Hasa weight rating10 000 -< INDICATE NORTH cWin)o p0 ,-,1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } I ® _ } (example:shuttle or charter bus):or C) 1gr r r g d 3. Is designed to carry 15 or fewer passengers and operated by a contract career i O -- -- - } } } transporting employees In the course of their employment(example:employee � ' .-- transporter-usually a van type vehicle or passenger car):or co L 4. Is used or designated to transport between 9 and 15 passengers,including y }--- ----; - } } } g po passen rs,includi the driver, . • for direct compensation(example:large van used for specific purpose):or L L____a____� j w r " nMO t——S-'---- On ® c- iany t 5. Is any vehicle used to transport hazardous material(HAZMAT)that requires m - placarding cartling(example:placards will be displayed on the vehicle). XI M 4.o.i.m Aw - _7 CARRIER NAME Z ADDRESS 0 w n CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate 0 Intrastate Aar wsow I ' ' ' ❑ Not in Comm./Govt. 0 Not in Comm./Other 00 -----------1 - USDOT NO. ILCC NO. C m XI Source of above Z . ❑ Yes 0 No 0 Unknown g D Did Carrier Safety Regulations MCS)violation contribute to the crash? ❑ Yes II No ElUnknown A 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 v TRAILER WIDTH(S) 0-96" 97-102" >102' m TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z White White u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 9 TOWED BY/TO: _ . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE