HomeMy WebLinkAbout2025-00066530 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003989906
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El5501-51.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER 91,500 El NOT ON SCENE(DESK REPORT) El Injury and f or Tow Due To Crash
0 AMENDED YR 2025I 2025-00066530 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
WILLARD AVE El 04:30
® ❑ RELATED ®Y 0 N 10 10 2025 12,— ❑YES ®NO U1
_ _ g PRIVATE mo !day!yr ®PM FLOW CONDITION m
FT!MI N E S W MACKEY LN COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR El SLOW 1 (/)❑ Cook HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
/83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 rary 0 NOV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
FROf4r TOWED U1
NAME(LAST,FIRST,M) Hernandez-Rodriguez.Adana. K. Mitsubishi Outlander 2022 oo-NONE „' Oi_, DUE 7oCRASH ❑ VIE
mo yr 13-UNDER CARRIAGE 10:) 2 2 FIRE ❑
lE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
F 2 SYTM 4 ❑Y ®SNE UNK VEH. O AT CRASH 0 99-U 15- NKNOWN THER9 76•TOP 3 *Distraction Value ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ iI 6 4 COM VEH 0 j$J 1 0
~ ELGIN I N I L 60124 0 1 0 FIRST CONTACT 12 7 ;1 _5 *Ir Yes.See Sidebar Ut
Z FC87458 IL 2025 Ismi
TELEPHONE
IL D 0 JA4J4VA81 NZ071618 Progressive ❑Y Igl N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
9 Same 862719912 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused El El 2 eu
p; DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑
1 9 9 0 Subaru XV Crosstrek 2.0 2017 00-NONE ,�_"i Qr O DUE TO CRASH ❑ 2
0 13-UNDER CARRIAGE 10( I 2 FIRE 0 ® U2 C
P.
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 1,6-TOP 3 X
❑Y IZ N ❑UNK VEH. AT CRASH 99-UNKNOWN *OistractIon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 1, COM VEH ❑ ® U1 CO
FIRST CONTACT 1 7�- _, _5 •If Yes,See Sidebar
116° ELGIN IL 60123 0 1 0 CC47201 IL 2025 REAR 0
IL D 0 J F2G PABCXH H253946 Progressive ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 934906472 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 2 10,10 ,2025 04 30 0 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
o"
2 0 2 99 ) t ❑PM• 0 Construction
R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM 0 Maintenance U2
o1 ® 11 1 ARREST NAME Hernandez-Rodriguez.Adana. K. 11-901-A (W)455-441 / ! ❑PM SLMT
o N
❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' ❑Utility
r 2 0 ARREST NAME AM
cc30
T 1 r ❑❑PM 0 Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 - El Workers present? ❑Y 30
455 HallaE.Gabriel 302 , , ❑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 -<
` ` ' ' r INDICATE NORTH combination):or p3
IL 1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
(example:shuttle or charter bus):or n
r r X
L L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier O
} } } transporting employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
L 4. Is used or designated to transport between 9 and 15 passengers,including N
}--- ----; orriw .ands: - } } } g po passen rs,includi the driver,
for direct compensation(example:large van used for specific purpose):or
' L____a____. - -- _ L t 5. Is anyvehicle used to transport anyhazardous material(HAZMAT)that requires
m
_ -5 _ placarding(example:placards will be displayed on the vehicle). XI
i i CARRIER NAME Z
11 .11
• 4 O
ILADDRESS
WW2 N
I Not To Scale CITY/STATE/ZIP
- - i. i. i. i. 4. MOTOR CARR.ID ❑ Interstate ❑ Intrastate
0
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
--'-------1 - USDOT NO. ILCC NO. m
XI
Source of above z
❑ 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
Black White
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ti 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