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HomeMy WebLinkAbout2025-00069388 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111 IIIIII II II II III IIIII I 11111111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004003268 u, 1 U21 1 1 1 U1 2 U2 1 U, 1 u2 1 U, 1 U2 1 5 10 u1 3 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ❑5501-51.500 ®ON SCENE 2 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash 0 AMENDED YR 2025I 2025-00069388 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 m ® ❑ RELATED PRIVATE ❑Y ®N 10 23 2025 ❑AM ❑YES ®NO U1 -< SUMMIT ST Elgin mo /day/yr 08'18 ®PM FLOW CONDITION m ®154F ,MI NOS W HIAWATHA Dr COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 15 u) Cook HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 5 C) 0 7 / yr 13-UNDER CARRIAGE ©, :•: FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 5 M M 2 5 El ®SNE❑UNK VEH. 0 AT CRASH IN ENGAGED0 99-UUNKNOWN 916•TOP 3 `Distraction Value ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s it 6 4 COM VEH ❑ Ea 1 0 ~ ELGIN I L 60120 B 1 0 FIRST CONTACT 12 7_; __5 C. uYes.See Sidebar U1 ZEG86951 IL 2026 ' E TELEPHONE IL D 0 KM85C73E55U966596 NONE ❑Y ®N U2 1- 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Elgin Fire 99 9 URIOSTEGUI. MARIANA NONE 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 1 yr 9 9 6 Chevrolet Trax 2025 00-NONE 10' 12 (_2 FIRE DUE OCRASH D D U2 2 C o mo 13-UNDER CARRIAGE c M 2 8 SYSTEM IN 0 ENGAGED 0 15-OTHER 911,6•TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN •Oistractlon Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8- 1. 6 j1:,_4 Com VEH D ® U1 CO FIRST CONTACT 2 7�. -5 •If Yes.See Sidebar H ELGIN IL 60123 B 1 0 16739NG IL 2026 I0 IL D 0 KL77LGEP9SC292976 PROGRESSIVE ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Elgin Fire 99 9 Same 861871329 BAG $ 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),(ADDRESS),(TELEPHONE) (EMS) (HOSPITAL) DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 1 ComEd COMED POLE AND BOX 10,23 ,2025 08 18 ®AM in a Work Zone? ®N DIRP co 1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 4 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C) 2 ❑ 1300 SPAULDING RD ELGIN IL 60120 2 18 10,23 ,2025 08 18 pM ® • ❑Construction * R 3 ❑ igi CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 z J ❑AM ❑Maintenance U2 o ® 11 1 ARREST NAME Uriostegui.Gabino •11-601-Ax 433001538 10,23 r2025 08 21 Igi pM SLMT I$!CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM• ❑Utility c Ti 2 ❑ 31 2 ARREST NAME Uriostegui.Gabino 3-707 433001539 10,23 ,2025 09 03 ®PM ❑Unknown work zone type U1 co 35 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 35 433-Miracle. Matthew 202 11 , 18,2025 01 30 0 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 -< c ` -'- ' r INDICATE NORTH combination):or —I y�d"errmm BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C 7 } (example:shuttle or charter bus):or X 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 Unk 1 1 4. Is used or designated to transport between 9 and 15 passengers,including ((I) } } } g po the driver, -- -- J I C I N_ - for direct compensation(example:large van used for specific purpose):or O ___ j_ i. < 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m placarding(example:placards will be displayed on the vehicle). ;p _ CARRIER NAME Z ——_ ,� i - ADDRESS D 1Hr 0 CITY/STATE/ZIP n MOTOR CARR.ID 0 Interstate 0 Intrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other ;------ --. - USDOT NO. ILCC NO. m XI Source of above z . —I 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 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 Silver Black u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. Arties/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 Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE