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HomeMy WebLinkAbout2025-00060509 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 6 Sheets 01111101111 I011011001 011 IIIII III IIIIII DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00396856/ u, 1 U21 1 1 1 U1 4 U2 1 U1 1 U2 1 U, 1 U2 1 1 14 U,26 U2 1 *P 0119 INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El5501-51.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash 0 AMENDED YR 2025I 2025-00060509 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ® ❑ RELATED PRIVATE ❑Y ®N 09 14 2025 ❑AM ❑YES ®NO U1 -< WING ST Elgin mo /day/yr 04:30 ®PM FLOW CONDITION Ill �O 1C.'J!MI N E S ® Lasalle St COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n Kane HIT&RUN ❑Y ® N WITH VEHICLESOT, INVLD DO STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Ig:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0 FOR DAMAGEDAREA(S) FROPtf TOWED U1 Q Hernandez. Maike. E. 0 7 / yr 13-UNDER CARRIAGE I FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 2 DISTRACTED 0 0 U2 4 <<Tl M 2 SY8 ❑Y ONM❑UNK VEH. O AT CRASH IN O 99-UNKNOWN 9 76•TOP 3 *Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, i�6 Ii 4 COM VEH 0 0 4 0 ELGIN IL 60123 0 1 FIRST CONTACT 11 7_: __5 *Il sees.See Sidebar U1 Z EF85493 IL 2025 REAR TELEPHONE IL Other 0 2CKDL33F586301966 None ❑v ®N U2 63 . m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Lezama Ortega.Yennys.J. None 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y El 2 eu p; DRIVER ❑ PARKED 0 DRIVERLESS 0 PEO 0 PEDAL 0 EWES 0 NIAV 0 i v 0 Dv '1 9 9 0 Mitsubishi Outlander 2020' 00-NONE al z j--_, DUE TO CRASH 0 ❑ 2 x 0 13-UNDER CARRIAGE 6 I ©(. 2 FIRE ❑ ® U2 C c F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 11:, 4 COM VEH D ® U1 CO FIRST CONTACT 11 7� __5 •If Yes.See Sidebar H ELGIN IL 60123 0 1 FM32575 IL 2025 REAR M IL D JA4AD3A3XLZ003260 None ❑Y ❑N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same None BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 < Refused RESPONDER U1 = (UNIT) (SEAT) (DOBi (SEX) {SAFT) (AIR) OHM 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 2 6 11 / ' D / / 4 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 09/14 /2025 04 30 ®pm in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 8 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 0 2 ❑ 20 28 1 / ❑PM ❑Construction >F Z 3 ❑ DygCITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 4 ❑AM ❑Maintenance U2 o ® 11 1 ARREST NAME Hernandez. Maike. E. 11-601 498001437 / / El PM SLMT El CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME NAM• • 0 Utility r 2 ❑ ARREST NAME Hernandez. Maike. E. 11-708 498001436 09/14 /2025 05 30 0 PM ❑Unknown work zone type U1 30 2 23 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30 498-Johnson.Andrew 602 269-Mendiola 10 ,28/2025 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•---, , - ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z I / 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< i- }-- --I-- --' 1 / INDICATE NORTH combination):or -I 3 V I f ff ARROW 2 Is used or designed to transport more than 15 passengers including the driver C i_ � i I I } (example:shuttle or charter bus):or 0 Y t 1 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O } -A- -•i transportingemployees In the course of their employment(example:employee �\ ® transporter usuall a van type vehicle or passenger car):or w L ` 4. Is used or desi nated to trans rt between 9 and 15 ge ng N }---..i.. .-; cfte ` } } } g po passen rs,includi [he driver, for direct compensation(example:large van used for specific purpose):or L L----a-- � ' \ ® i. i. i. L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m vmnaaae placarding(example:placards will be displayed on the vehicle). ;p CARRIER NAME Z ADDRESS D 'n `® III ® I I I CITY/STATE/ZIP 0 NorA3Mr� g l I i MOTOR CARR.ID ❑ Interstate ❑ Intrastate r Ii. 1 I 1 I I I ❑ Not in Comm./Govt. Not in Comm./Other 0 ‘I. - --1 USDOT NO. ILCC NO. m XI Source of above 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 Red Black u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. Redmons/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 Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE