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HomeMy WebLinkAbout2025-00065671 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 I011011001 00111100 DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X003989985 u, 1 U21 1 1 2 U, 4 U2 1 U, 1 U2 1 U1 1 U2 1 5 11 U1 1 U211 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash El AMENDED YR 2025I 2025-00065671 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 �I ® ❑ RELATED ❑Y ®N 10 07 2025 ®AM ❑YES ®NO U1 -< ROUTE 20 HWY Elgin 06:12 _ _ g PRIVATE mo !day!yr ❑PM FLOW CONDITION m 75 !MI N E S Shales Pk COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 u) ® ® © Cook 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 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 n 0 2 ! yr 13-UNDER CARRIAGE 16) 2 , 2 FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 4 rn M 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 16•TOP 3 _ ❑N [DUNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6,_iL 6 1,.4 COM VEH ❑ Ei 2 O ~ ELGIN I L 60123 0 1 0 FIRST CONTACT 12 7 ; _5 *II Yes.See Sidebar U1 Z 2832897B IL 2026 REAR TELEPHONE IL D 3TMCZ5AN7N M460349 State Farm ❑Y ®N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR co Same 3649497SFP13 2 m o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y El 2 c p; DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 !2 0 0 6 Ford Edge 2018 00-NONE +i_"i 12..-_, DUETO CRASH ❑ !g 2 oYr 13-UNDERCARRIAGE 10;1 2 FIRE ❑ ® U2 C c M 2 4 SYSTEM IN ENGAGED 15-OTHER 9 16•TOP 3 3 X ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistrac on Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 iI 6 l,,_4 COM VEH D ® Ut CO FIRST CONTACT 6 Y__{_0 -5 •If Yes.See Sidebar H ELGIN IL 60123 0 1 0 EL32610 IL 2026aR M IL D 2FM PK3G91 J BC35002 Integon Casualty ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Diaz-Del Carpio,Adolfo 2028258556 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 1 10,07 l2025 06 12 ®❑AM 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) o" 2 ❑ 28 99 + ! ❑PM. ❑Construction * ❑ 4 Z 3 0 Dyg CITATIONS ISSUED 3 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM Maintenance U2 a ® 11 1 ARREST NAME Heffernan, Benny,J. 11-601-Ax 298001321 , ! ❑PM SLMT I$!CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility o N DI CI t 2 El ARREST NAME Arroyo. Bryan.C. 3-703 298001322 , r PM Unknown work zone type U1 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 45 298-Lopez, Mirko 302 11 , 18,2025 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••--, , L.-,;I : A CMV is defined as any motor vehicle used to transport passengers or property and: Z i- --; ;I Polononlmpect ( i I 'C I 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer combination):or -< - —II INDICATE NORTH p3 >..; BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C i.w (example:shuttle or charter bus):or 0 :D r Q�� 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 � _A. -.� - I I. l- I- transporting employees In the course of their employment(example:employee X . rter- i.__-A_-__ Not To Scale - •4alsuosedordestlnatedtotrans vehicle rtbetween9andr15r) C ssen rs,including[he driver, I } } } for direct compensation(examp large van used for specific purpose):or L L--_-a-.... I L i L 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'u placarding(example:placards will be displayed on the vehicle). m x1 ICARRIER NAME Z I ADDRESS 0 D / CITY/STATE/ZIP 0 MOTOR CARR.ID 0 Interstate 0 Intrastate amt«rnkwy. O I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other ----------1 • - USDOT NO. ILCC NO. m XI Source of above z ' . Form Number m Xl IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2 TRAILER VIN 1 m co LOCAL USE ONLY TRAILER VIN 2 m a 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 Green White u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO: _Redmons SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO: DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE