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HomeMy WebLinkAbout2025-00070373 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 0110 NN II 10 0010111111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004OO8544 u, 1 U21 2 4 1 U, 2 U2 1 U, 1 1_12 1 U, 1 U2 1 1 10 U1 1 U2 3 *P 0119 INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) El AMENDED ElB Injury and for Tow Due To Crash YR 2025I 2025-00070373 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ® ❑ RELATED ®Y ❑N 10 28 2025 ❑AM ❑YES ®NO U1 —< CLEVELAND AVE Elgin05:01 _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m FT!MI N E S W BENT ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n ❑ Cook HIT&RUN ❑Y ® N WITH VEHICLESOT, INVLD ❑ STOPPED U2 —I Igl AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NOV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 n 0 9 ! yr 13-UNDER CARRIAGE ©{O!- FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) EN O 2 DISTRACTED 0 0U2 0 m F 2 SY4 ❑Y ®SNE❑UNK VEH. O AT CRASH M IN ENGAGED0 99-UNKNOWN 9 76•TOP 3 *Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, i�6 �i 4 COM VEH 0 j$J 1 0 ELGIN I L 60120 0 1 0 FIRST CONTACT 11 7_: __5 *II Ves.See Sidebar U1 Z DJ22845 IL 2026 REAR TELEPHONE IL D 0 4T4BE46K79R114496 Geico Insurance ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Urzua.Carlos 6207095453 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER 2 XI x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uv 0 NOV 0 DV !1 9 yr7 Nissan Pathfinder 2018 00-NONE „ 12.._, DUE TO CRASH ❑ 2 x o - 13-UNDER CARRIAGE FIRE ID El U2 II F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 016-TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF O I 6 ,•',.4 COM VEH ❑ ® U1 CO FIRST CONTACT 9 O7 1_,__s •If Yes.See Sidebar C ELGIN IL 60120 0 1 0 AU53556 IL 2026 REAR 0 Si) Z IL D 0 5N1 DR2MM4JC664376 Statefarm ❑Y J N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Hernandez.Sergio. E. 1141634SFP13 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = KNIT) (SEAT) (DOB) (SEX) {SAFT) (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 0 Y U2 Z co N 1 CD 11 4 10,28 l2025 05 01 ®Pmm� in a Work Zone? ®N o1RP > 1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 1 C) o" T 2 ❑ 2 99 / ! 0 PM• ❑Construction * Z 3 ❑ I!!I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 ❑AM ❑Maintenance U2 o1 ® 11 4 ARREST NAME Urzua. Dyanne.A. 11-901-A W1500000396 ! ! El PM SLMT o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility 0 AM t 2 El ARREST NAME 10 r 28 12025 05 47 ®PM El Unknown work zone type U1 35 T n OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ - ❑AM Workers present? ❑Y 35 1500-Chew. Marie 401 , , ❑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 } } ' ' I A } INDICATE NORTH 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer combination):or -< p0 N i BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C I ti _ } (example:shuttle or charter bus):or 3. Is designed to carry15 or fewer passengers and operated a contract carrier O Not To Scale I - }} } transporting employee In the course of their employment(example:employee transporter-usually a van type vehicle or passenger car):or w L L.__-a__- ear \ 4. Is used ordesi natedtotrans rtbetween9and15 ge ng y} } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or O %.. - i i 5. Is any vehicle used to transport an hazardous material(HAZMA that requires placarding(example:placards will be displayed on the vehicle). XI ICI CARRIER NAME Z It—i - 0 ADDRESS 9 u,h1 T V) iCITY/STATE/ZIP C) V - MOTOR CARR.ID 0 Interstate ❑ Intrastate I I T I ❑ Not in Comm./Govt. ❑ Not in Comm./Other o r _...Y._._1 - USDOT NO. ILCC NO. m XI Source of above z . xi 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 Blue 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