HomeMy WebLinkAbout2025-00064631 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
011011001
IIIIIIII I!III I1111
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XO03'983269
u, 1 U21 2 4 1 U1 2 U2 1 U, 1 1_12 1 U, 1 U2 1 1 15 U1 1 U2 1 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
❑AMENDED ❑ B Injury and for Tow Due To Crash YR 2025I 2025-00064631 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
SHERMAN AVE Elgin01:47
® ❑ RELATED ®Y 0 N 10 02 2025 ❑AM ❑YES E)NO U1 -<
_ _ PRIVATE mo !day/yr ®PM FLOW CONDITION MFT!MI N E S W ILLINOIS NOIS AVE COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 1 (n
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 NIA/ 0!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
F tf TOWED U1 Q
NAME(LAST,FIRST,M) Patterson. Eric. D. mo yr q
Chevrolet Equinox 2020 00-NONE DUE TO CRASH ❑ EN
13-UNDER CARRIAGE N,..! 12! 2 FIRE 0 ® E
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 1U 2 DISTRACTED 0 0 U2 0 rr1
M 2 4 SYTM❑Y ®SNE❑UNK VEH. 0 AT CRASH 0 15-99-UNKNOWN THER9 16•T DP 3 *Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�B �i 4 COM VEH 0 0 1 0
F. FIRST CONTACT 1 7 ;—_;__5 *Irves.See Sidebar Ut
V Z Calumet City IL 60409 0 1 0 E U 18849 IL 2026 REAR
TELEPHONE
IL D 0 3G NAXH EV8LS658429 Progressive ❑Y IlN U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Wise. Hermine. L. 982901417 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 XI
Eg DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑NMy 0 NCv ❑DV
!2 O 0 2 Dodge Caravan(inc Grand)2017 oo-NONE 0t2.._1 DUE TO CRASH ❑ 2 x
Tiy Yr 13-UNDER CARRIAGE 10 I 2 FIRE ❑ ® U2 C
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN *Oistrac on Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8
-iI�1:, 4 COM VEH ❑ ® U1 W
FIRST CONTACT 11 7 _5 •If Yes.See SidebarC
F-
. . ELGIN IL 60120 0 1 0 BD80947 IL 2026 REAR— 0
IL D 0 2C4RDGCG4HR818362 Allstate ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
99 9 Gonzalez. Ezequiel 811493736 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (D0131 (SEX) {SAFT) (AIR) (WI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(A.DDRESS)r(TELEPHONE! (EMS) (HOSPITAL)
1 3 06 / M 2 3 0 1 0
m
/ / #OCCS D
71
/ / UI 2 D
/ / 1 0
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 4 10,02 l2025 01 47 ®PM in a Work Zone? ®N DIRP co
1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 3 C)
T
0
2 ❑ 2 99 1 / ❑PM• ❑Construction
1
Z3 ❑ I!!I CITATIONS ISSUED ElPENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5
-, ® 11 4 ARREST NAME Patterson. Eric. D. 11-901-A W1538000321 / ! El PM SLMT
o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility
30
t 2 ARREST NAME AM
T 1 r ❑❑PM ❑Unknown work zone type U1
El
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ 1538-Estrada. Leticia 400 360-Yucaitis , ! ❑❑PM Workers present? ®N U2 30
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 truckrtrailer -<
` ` -' -' r INDICATE NORTH combination):or .Z-1
® BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
_ (example:shuttle or charter bus):or
3. Is designed to carry15 or fewer passengers and operated a contract carrier O
-- Not To Scale I - I. } . transporting employee in the course of their employment(example:employee X
i I transporter-usually a van type vehicle or passenger car):or CO
L L.___a____� I 1 •4. Is used ordesi natedtotrans rtbetween9and15passengers,includingthedriver,
C
a } } for direct compensation(examp large van used for speific purose):or 0L1...."—
t i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
r m
vos. placarding(example:placards will be displayed on the vehicle).
— — (.._=r' — 2#
CARRIER NAME Z
—4 1 0
i v. shemlan9Ave ADDRESS
w
CITY/STATE/ZIP 0
g
MOTOR CARR.ID 0 Interstate ❑ Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
-----—: - USDOT NO. ILCC NO. rn
XI
Source of above Z
. ❑ Yes 0 No 0 Unknown g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash? A
❑ Yes No ❑ 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'; 0 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' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Silver Silver
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 1 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