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HomeMy WebLinkAbout2025-00067618 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II III HH II11II OUI 00110000111011�1111111111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003998153 u, 9 U21 2 4 1 U199 U2 1 u,99 u2 1 u, 1 U2 1 1 10 u, 4 U2 1 *P 0119 INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 15 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) El AMENDED ElB Injury and/or Tow Due To Crash YR 202512025-00067618 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I VALLEY CREEK DR EIin ® ❑ RELATED ®Y 0 N 10 16 2025 08:49 ®AM YES ®NO U1 -< _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION ITT FT!MI N E S W N AI RLITE ST COUNTY PROPERTY ElY ® N DOORING ICIy #OF MOTOR El SLOW 1 (/)❑ Kane 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 Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NIA/ ❑ncv ❑ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n 10 FOR DAMAGEDAREA(S) FRONT TOWED U1 Q 2011 Buick Enclave 00-NONE , DUE TO CRASH ❑ EN NAME(LAST,FIRST,M) Juarez Gutierrez.Janet mo / / yr ©1 12 E 13-UNDER CARRIAGE 10 1 2 FIRE 0IE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 rn F 2 SYTM 4 ❑Y ®SNE DUNK VEH. O AT CRASH 0 99-UNK15- NOWN THER9 16•TOP 3 *Distraction Value ALGN X. r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�S �i 4 COM VEH ❑ Ea 1 0 ELGIN I L 60123 0 1 0 FIRST CONTACT 11 7_: __5 *Ilsees.See Sidebar U1 ZDM91085 IL 2026 REAR TELEPHONE IL D 0 SGAKRBED1 BJ339032 Allstate ❑Y ®N U2 I' in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Saldivar.Jose 979915663 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 eu m x DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEOAL 0 EWES 0 Nuy 0 Ncv ❑ CIRCLE NUMBER(S) U1 Dv /1 9$2 Toyota Camry 2025 00-NONE 'o, t2 c 2 FIRE DUE OCRASH D ® 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 ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istraellon Value 9 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 i� 6 1,:,,,COM VEH ❑ ® U1 W F,,, FIRST CONTACT 5 7�_ S •IfYes.See Sidebar ELGIN IL 60123 0 1 0 FC23351 IL 2025 REAR M IL D 0 4T1 DBADKOSU022875 State Farm ❑Y ®N RDEF71 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Same 2079300SFP13 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER u1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(A.DDRESS)/(TELEPHONE) (EMS) (HOSPITAL) 2 4 11 / DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 9 10/16 /2025 08 49 ®❑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 7 C) T rn 2 0 28 2 / / ❑PM ❑Construction Z3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 1 -a, ARREST NAME / / El PM ' ou ® 11 4 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT t 2 ❑ ARREST NAME AM T / / pM 0 Unknown work zone type 30 U1 n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 30 436-Lagodzinski. Brian 602 - / / ❑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 I 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 -< ` ` --I -' I r INDICATE NORTH �mb natbn)or ' N BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C _ } (example:shuttle or charter bus):or Not To Scale I 0 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I } } } transporting employees in the course of their employment(example:employee X transporter-usually a van type vehicle or passenger car):or w L }-----}----+ + I. } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver. N I • !� for direct compensation(example:large van used for specific purpose):or L L____a____.I. O ;tp N?Afrritepsyfe, - t } } } 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m placarding(example:placards will be displayed on the vehicle). ;p fl CARRIER NAME Z ADDRESS 0 C) CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate 0 Intrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other II- Ir --- --1 USDOT NO. ILCC NO. m XI Source of above z . If Yes,Name on placard O 4 digit UN NO. 1 digit Hazard class No. Xl Xl Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z own tank)? 0 Yes 0 No 0 Unknown Did HAZMAT Regulations violation contribute to the crash? r ❑ 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 Beige Red u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 2 TOWED BY/TO: _ . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO. DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE