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HomeMy WebLinkAbout2025-00068987 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Df 2 Sheets 01111101111 0110 111110 011101111111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004006562` u, 1 U21 2 1 1 U1 5 U2 1 U1 1 U2 1 U1 1 U2 1 4 10 U, 3 U2 1 *P 0119 INVESTIGATING AGENCY DAMAGE TO ANY El 5500 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 2 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash 0 AMENDED YR 2025I 2025-00068987 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1 ® ❑ RELATED ' V 0 N 10 22 2025 ®AM ❑YES ®NO U1 -< DUNCAN AVE Elgin05Ag _ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m FTlMI N E S W SLADE AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 1 (n ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLESOT, INVLD ❑ STOPPED U2 --I CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 Qg)DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 11Av 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C) FOR DAMAGEDAREA(S) 1380N1 TOWED U1 Q Fuentes-Diaz. Miguel,A. 0 5 / yr 13-UNDER CARRIAGE ©,I ,._Z FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m M 2 SY4 ❑Y ®SNE❑UNK VEH. O AT CRASM IN H O 99-UNKNOWN 916•TOP 3 `Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s it a ii,4 COM VEH 0 j$J 1 0 ELGIN I L 60120 0 1 0 FIRST CONTACT 11 7_;1 -__S *II Yes.See Sidebar U1 ZCL30559 IL 2026 REAR TELEPHONE IL D 0 KMHDU4ADXAU934199 Kemper Insurance ❑Y Il N U2 11 , m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m co 99 9 Same 12AU001486572 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER en Refused ❑Y ® N 2 0 m x DRIVER ❑ PARKED 0 DRIVERLESS 0 PEO 0 PEDAL 0 EWES 0 rMv 0 KCv 0 Dv CIRCLE NUMBER(S) U1 1 9 9 6 Honda Accord 2017 00-NONE O Q�-O DUE TO CRASH ❑ 2 0 13-UNDER CARRIAGE 10( I 2 FIRE ❑ ® U2 C c F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X ❑Y NJ N DUNK VEH. AT CRASH 99-UNKNOWN `0istrac on VaIue 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s-il 6 I1:, 4 COM VEH ❑ ® U1 CO FIRST CONTACT 12 7� .5 •(ryes.See Sidebar H ELGIN IL 60120 0 1 0 DP42326 IL 2026 I 0 C M IL D 0 1 HGCT1 B64HA005706 State Farm ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Same 116506-SFP-13 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER ut = (UNIT) (SEAT) (DOB) (SEX) {SART) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 1 0 EV MOST EVNT LOC, DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 1 10,22 r2025 05 49 ®❑pM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 0 2 ❑ 20 99 1 r ❑PM ❑Construction * R 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM ❑Maintenance U2 -a, ARREST NAME Fuentes-Diaz, Miguel,A. 11-708 S1544-000229 r r El PM SLMT o U 1 ® 1 1 1 CITATIONS ISSUED 0PENDING TIME ❑Utility o N SECTION CITATION NO. ROAD CLEARANCE DI AM 30 F 2 ❑ ARREST NAME Fuentes-Diaz, Miguel,A. 11-601-Ax S1544-000230 ( r PM ❑Unknown work zone type U1 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 30 1544-Solis,Yulissa 981 331-Ziegler 11 , 18(2025 01 30 ®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 -< i- }--__r-_--; I. INDICATE NORTH combination):or —I p1 IBY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C N ; r r r (example:shuttle or charter bus):or o I T, 3. Is d ned t carry 15 or fewer passengers and operated a contract carrier 0 }. -A- --i esig o pa g pe I - } } } transporting employees In the course of their employment(example:employee � X ' transporter-usually a van type vehicle or passenger car):or CO L 4. Is used or designated to transport between 9 and 15 passengers,including C---- ----; - } } } g po passen rs,includi the driver, t for direct compensation(example:large van used for specific purpose):or O I. I_ __I_ . _ _ _ - l. i i 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires rn placarding(example:placards will be displayed on the vehicle). ;p —1 CARRIER NAME Z ADDRESS T. CITY/STATE/ZIP 0 Not To Scale I MOTOR CARR.ID 0 Interstate 0 Intrastate 1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other --- --4. - USDOT NO. ILCC NO. m XI Source of above z . If Yes,Name on placard 0 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 to 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 Blue Gray 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 DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE