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HomeMy WebLinkAbout2025-00062556 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I011011001 011 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003969835 u, 1 U21 2 4 1 U1 2 U2 1 U, 1 1_12 1 1.11 1 U2 1 1 15 u1 1 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El 5500 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 8 VEHICLE/PROPERTY El OVER$1,500 El NOT ON SCENE(DESK REPORT) (83B Injury and/or Tow Due To Crash 0 AMENDED YR 202512025-00062556 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 mNESLER RD 1 GANSETT PKWY Elgin ® ❑ RELATED ®Y 0 N 09 23 2025 ❑AM ❑YES ®NO U1 '‹ PRIVATE mo /day/yr 05:42 ®PM FLOW CONDITION M ®20 ®!MI N E S © NESLER RD/GANSETT PKWY COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 u) Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I 0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 (gl DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 SIN 0 ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 00 0 FOR DAMAGED AREA(S) FROr T TOWED U1 0Hernandez Brach°.Gor.Y. 0 5 / yr 13-UNDER CARRIAGE 10 2 FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 !3 U2 OO M M 2 SY 15-OTHER 4 ❑Y ®SNE❑UNK VEH. O AT CRASH M IN D O 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�S 4 COM VEH 0 Ea 1 0 F. FIRST CONTACT 12 7_:— ___, _5 *lives.See Sidebar U1 Z ORLANDO FL 32819 0 1 0 FH70134 IL 2026 REAR TELEPHONE FL Other 0 1 C4SJSBP8RS103650 Allstate ❑Y ®N U2 13 . m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Elgin Fire 99 9 Hernandez, Irina 979743695 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 eu p; DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEOAL 0 EWES 0 NIAV 0 NOV ❑Dv CIRCLE NUMBER(S) U1 /2 Yr 0 0 3 Subaru Outback 2021 00-NONE 'o,I t2 (,�2 FIRE DUE ID CRASH D D U2 2 C o mo 13-UNDER CARRIAGE c M 2 8 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X ❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN *Oistraglon Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s FIRST CONTACT 10 7- 1 6 it4 C•ItOMYes VEH.See Sidebar❑ ® U1 CO _SOS ELGIN IL 60124 0 1 0 CR13828 IL 2026 IL D 0 4S4BTAMC3M3158780 Statefarm ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X Elgin Fire 99 9 Veeramasuneni, Nithin, K. 0858274SFP13 SAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP ui = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME))(A.DDRESS)/(TELEPHONE) (EMS) (HOSPITAL) U2 m ##OCCS y / / U1 1 D / / 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 4 09,23 /2025 05 42 ®AM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C) v 2 ❑ 28 2 09,23 /2025 05 54 ®PM ❑Construction >E R 3 ❑ xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM ❑Maintenance U2 o1 ® 11 4 ARREST NAME Hernandez Bracho,Gor,Y. 11-601-Ax S1509-166 09/23/2025 06 00 ®pm SLMT o0 Am N 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility t 2 El 3 ARREST NAME 09/23 /2025 06 35 ®PM ❑Unknown work zone type U1 45 2 2 3 D OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 45 1509-Wortman,Cassie 801 10 ,21 ,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 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< combination):or p0p- INDICATE NORTH( ) BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C �� _ } (example:shuttle or charter bus):or 0 X I- ----$----1 .�. Not?To?Scala 1 - } } } transporting empld to oyees he course of r he r rs employment employeerier X ,, �' transporter-usually a van type vehicle or passenger car):(example:r CO L L.___a__-_.I 1 } 4. Is used ordesi natedtotrans rtbetween9and15passengers,includingthedriver. C } } for direct compensation(example:large van used for speific purose):or 0 L L--_-a-___� �°" t l. I. 1 5. Is any vehicle used to transport an hazardous material(HAZMAT)that requires m 4w, placarding(example:placards will be displayed on the vehicle). XI Ds..titi CARRIER NAME —I Z 7/-/TADDRESS 0 T. CITY/STATE/ZIP 00 MOTOR CARR.ID 0 Interstate 0 Intrastate I r ❑ 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 Gray Gray u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO. 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