HomeMy WebLinkAbout2025-00067074 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets II 111 I M 11111111 110000 III I D I11110
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XoO3992a53
u, 9 u21 3 4 1 U199 U2 1 U199 1_12 1 U,99 U2 1 1 11 U199 U2 1 *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 El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500
El NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 2025I 2025-00067074 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 71
® ❑ RELATED PRIVATE ❑Y ®N 10 13 2025 DAM ❑YES ®NO U1 '<
S STATE ST Elgin mo /day/yr 05:46 ®PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 15 u)
00 Or MI N E p W Lord St WITH VEHICLES INVLD 0 STOPPED U2 --I
El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN I2J Y ElN PEDALCYCLIST®N ® FREE FLOW # LNS 0
18:DRIVER ❑ PARKED 0 DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FOR DAMAGEDAREA(S) FRO TOWED U1 0NAME(LAST,FIRST,M) mo yr
Unknown.0. / / r T Chevrolet Avalanche 2002 00-NONE Q 0i 0 DUE TO CRASH ❑ VI
13-UNDER CARRIAGE 10.I 2 FIRE 0 IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTEDU2 2 <
9 9 SYSTEM IN
Y O ENGAGED 0 15-OTHER 9 16.TOP 3 0 _
❑ ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF it s i.4 COM VEH 0 El 1 0
~ 0 9 0 FIRST CONTACT 12 7_; __5 *If Yes.See Sidebar Ut
Z 4177433B IL 2025
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 11/
3G N EK13T92G242156 unknown ❑v ❑N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
99 9 Collins. Dre. L. unnknown 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER
99 0
m x DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED ❑PEDAL 0 EWES O Nuv 0 KV ❑DV CIRCLE NUMBER(S) U1
yr
/1 9 9 8 Kia Motors Colpoul 2010 00-NONE 10 t2 ( 2 FIRE DUE ocRASH ® U2 2 C
o 13-UNDER CARRIAGE
c
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X
❑Y i N 0 UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 9
POINT OF s i —4 COM VEH ❑ ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6
FIRST CONTACT 6 O7 ,�=QIOS •)ryes See Sidebar C
z WEST DUNDEE IL 60118 0 1 0 EQ17057 IL 2025aR 0 Si)
IL D KNDJT2A20A7183738 AllState ❑y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
99 9 Hernandez.Gerardo 811402986 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
)UNIT) fSEATI (DOB) (SEX) {SAFT) (AIR) (INJ) 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS))TELEPHONE) (EMS) (HOSPITAL)
2 4 06 /
DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ®Y U2 Z
N 1 ® 11 9 10/13 /2025 05 46 ®AM in a Work Zone? ❑N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 0 18 99
N 3 ❑ 0 CITATIONS ISSUED 0 PENDING + / 0 PM• ®Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 5
z
—a, u ARREST NAME / / El PM '
1 ® 1 1 1UtilitySLMT
S' SECTION CITATION NO. ROAD CLEARANCE TIME 0
❑CITATIONS ISSUED PENDING
t 2 El ARREST NAME 10/13 /2025 06 00 0 PM El Unknown work zone type U1 El AM
30
T
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ ❑AM Workers present? ❑Y 30
1528 Rivera. Kevin 701 / / ❑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
T 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_-_-; } combination):or —I
INDICATE NORTH p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} I } (example:shuttle or charter bus):or
L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
} } } transporting employees In the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
L -----}----; I r I. } 1.} 4. Is used or designated to transport between 9 and 15 passengers,including the driver. C
for direct compensation(example:large van used for specific purpose):or
I L i. i. _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
Unitll placarding(example:placards will be displayed on the vehicle). XI
CARRIER NAME Z
I• ADDRESS o
UniCTi2 �• );#
CITY/STATE/ZIP 0
i. i. i. MOTOR CARR.ID 0 Interstate 0 Intrastate
I UO1"r "II ❑ Not in Comm.lGaA. 0 Not in Comm./Other
I I ---+ _ ,
Not 7a score I USDOT NO. ILCC NO. m
XI
Source of above z
IDOT PERMIT NO. WIDELOAD-; ❑Yes 0 No =
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 9 TOWED BY/TO.
SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Other/Unknown VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE