HomeMy WebLinkAbout2025-00068015 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003999385
u, 9 U2 1 1 1 U116 U216 U199 1_12 U,99 U2 1 4 9 U199 U221 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 7
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 2025512025-00068015 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 —1
300 S MCLEAN BLVD Elgin09:16
® ❑ RELATED 0 Y ®N 10 17 2025 DAM ❑YES ®NO U1
_ PRIVATE mo /day/yr ®PM FLOW CONDITION MCOUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ FT/MI N E S W Kane HIT ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I
El AT RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER O PARKED 0 DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 NW 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
/ ! FOR DAMAGEDAREA(S) MOM TOWED U1 0
Unknown.0. Unknown Unknown 00-NONE 11 • 12I-0 OUETOCRASH ❑
NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 101 2 FIRE 0 IE <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® 0 U2 !T1
SYSTEM IN ENGAGED 15-OTHER 9 76.TOP 3
F 9 9 ❑Y ❑N ❑UNK VEH. AT CRASH ®-UNKNOWN `Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s_iL 6)!.__i C.OM VEH ❑ El 1 0
~ 0 9 FIRST CONTACT 1 7_; __ *If Yes.See Sidebar Ut
Z UNKNOWN ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1)
UNKNOWN unknown ❑Y ®N U2 I—
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same unknown 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y El 99 0
❑ DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 iiuv 0 NOV 0 Dv CIRCLE NUMBER(S) U1
yr 10;j 12 c, 2 FIRE ❑ ElU2 1 C
o 13-UNDER CARRIAGE
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16
0 ® SPDR 0
❑Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value U1 0 -
POINT OF 8 ) -4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR S COM VEH ❑ ® CO
F,,, FIRST CONTACT 6 O7 ,�=QI OS •IfYes See Sidebar C
E747839 IL 2025
0 Si)
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
1 N4AL3AP3HC476042 State Farm 0 V ®N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 10 =
Cano Bautista, Efrain 2985896SFP13 BAG $
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)
2 3 11 / F 1 3 0 1
m
/ / #OCCS D
71
/ / U1 1 D
/ / 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 18 1 10/18 l2025 09 16 ®PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
2 0 18 99
N 3 ❑ ❑CITATIONS ISSUED 0 PENDING + ! ❑PM• El Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 7
—a, N IARREST NAME / / El PM '
El 11 1 0 CITATIONS ISSUED ❑PENDING UtilitySLMT
S' SECTION CITATION NO. ROAD CLEARANCE TIME 0
0 AM
n T
T 2 0 ARREST NAME 10/18 /2025 09 16 ®PM 0 Unknown work zone type U1 1 O
o' OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 - ❑AM Workers present? ❑Y 05
1535 Solis• Laura sot / ❑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
Unit 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
combination):or
r }----r----, � ��� ) INDICATE NORTH p1
.� ..,1� BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i I } (example:shuttle or charter bus):or
3. Is designed to carry 15 or fewer passengers and operated by a contract carrier O
I. } } transporting employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
4. Is used or designated to transport between 9 and 15 passengers,including wwjt
} } 1. •
for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or O
L ' ---. I seefa►Md ntel.a I L i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D
a placarding(example:placards will be displayed on the vehicle).
m
Not To Scale 1 XI
CARRIER NAME Z
(.... 1,2) ADDRESS 0
CITY/STATE/ZIP C)0
MOTOR CARR.ID 0 Interstate 0 Intrastate
r ; ❑ Not in Comm./Govt. 0 Not in Comm./Other
;------ --.; - USDOT NO. ILCC NO. m
XI
Source of above z
. GVWR/GCWR m
0 <10,0oo 0 10,000-26,000 0 >26,000 z
Were HAZMAT placards on vehicle? 0 Yes 0 No =
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
Black Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ElNOT DISABLING DAMAGE DAMAGE EXTENT- 9 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