HomeMy WebLinkAbout2025-00067133 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II I 111 IIII
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ®5501-$1.500 El ON SCENE 19
VEHICLE/PROPERTY ❑OVER$1,500 ®NOT ON SCENE(DESK REPORT)
El AMENDED ElB Injury and for Tow Due To Crash YR 202512025-00067133 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
® ❑ RELATED ®Y 0 N 10 14 2025 ®AM ❑YES ®NO U1 —<
SHALES PKWY Elgin07:06
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FTlMI N E S W SHELDON DR COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15
❑ Cook HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 --I
CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Qg)DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 00 n
FOR DAMAGEDAREA(S) FROM TOWED U1 Q
Hernandez.Julian 0 9 !
yr 13-UNDER CARRIAGE IE
.10' ! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0U2 00 r n<
M 2 SY 15-OTHER
4 ❑Y ®SNE❑UNK VEH. 0 AT CRASH M IN D 0 99-UNKNOWN 9 76•TOP 3 `Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 7 7_. --iI S ii,4 COM VEH ❑ j$J 1 0
F. FIRST CONTACT 1 ___5 *Yves.See Sidebar U1
Z Chicago IL 60639 0 1 0 FM74708 IL 2026 Ia, ;
TELEPHONE
IL D 0 SFNYF6H9XJB047529 Freeway Insurance SERV Am ❑v igi N U2 m
B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same ILU015508 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER XI
Refused ❑Y El 2 0
x DRIVER 0 PARKED 0 DRIVERLESS ❑ FED 0 PEDAL 0 EWES 0 uv 0 NCv 0 Dv
!1 9 8 5 Honda CRV 2017 00-NONE al 12 c 2 FIREOCRASH D ® U2 2 C
o yr 13-UNDER CARRIAGE
c
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 X
❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 0
i1 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF -, 1i 4 COM VEH ❑ ® U1 co
5
FIRST CONTACT 11 8 7 _5 •If Yes.See Sidebar
Z Chicago I L 60651 0 1 0 EV44204 I L 2025 REAR Chicago N
Z
IL D 0 7FARW1 H52HE048337 State Farm ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 1322346-SFP-13 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER®N u1 =
(UNIT) (SEAT) (0081 (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 CD 11 4 10,14 l2025 07 06 ®❑pM in a Work Zone? NJ o1RP co
1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 5 C)
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2 ❑ 2 15 , , ❑PM ❑Construction *
R 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
o1 ® 11 4 ARREST NAME Hernandez.Julian 11-801-B 1561-000124 / ! ❑PM SLMT
o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility
AM 35
t 2 El ARREST NAME 10,14 l2025 07 06 MPM ElUnknown work zone type U,
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 35
1561-Sarovic• Mirko 302 11 ,04,2025 09 00 ❑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.
A CMV is defined asmotor vehicle used to transportand:
r ----,5-••--, ; any passengers or property
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1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
} i.-- -i-- --; } } } r -, , ; ; , 1, ( INDICATE NORTH combination):or —I
p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ' i 1 , } (example:shuttle or charter bus):or
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3. Is L L.___A_. 1 i. <-- . -___� J transporting employened to es Inhecourse 5 or fewer o their eers mplod yment example:employeener X
} } }
transporter-usually a van type vehicle or passenger car):or CO
< <.__-a-_-_, , < <--_-a-___� , , , , 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or 0
L L___-a____.: L L L ...._-.�____� l. i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). XI
—D7
CARRIER NAME Z
ADDRESS 0
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other O
USDOT NO. ILCC NO. m
XI
Source of above z
. Form Number
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IDOT PERMIT NO. WIDELOAD'; 0 Yes 0 No 2
TRAILER VIN 1 m
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LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
White Gray
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