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HomeMy WebLinkAbout2025-00070383 ILLINOIS TRAFFIC CRASH REPORT sheet 1 Df 2 Sheets 01111101111 I0110 II 1111 III 11011�011111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV XO04OQB1BO u, 1 U21 1 1 1 U1 2 U2 1 U1 1 U2 1 U, 1 U2 1 3 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 ❑$501-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ElB Injury and for Tow Due To Crash YR 202512025-00070383 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 mPARK ST El 05:59 ® ❑ RELATED ' V 0 N 10 28 2025 ❑AM ❑YES ®NO U1 -< _ _ g PRIVATE mo !day!yr ®PM FLOW CONDITION m FT!MI N E S W COLLEGE ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR IR SLOW 15 u) ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0 FOR DAMAGEDAREA(S) .FROM TOWED U1 PEREZ.TERESA 0 3 / yr 13-UNDER CARRIAGE 10 I , 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m F 2 SY 15-OTHER 4 ❑Y ®SNE❑UNK VEH. 0 AT CRASH M IN D 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF & i�6 4 COM VEH 0 j$J 1 0 ~ ELGIN I L 60120 0 1 0 FIRST CONTACT 12 7_: __5 *lI Yes.See Sidebar U1 Z EP32816 IL 2026 REAR TELEPHONE IL D 0 2HKRW2H57HH636799 STATEFARM' ❑Y ®N U2 I''I B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m co Same 2598171SFP13 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER en Refused ❑Y ® N 2 0 x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMv 0 NCV 0 DV !1 9 9 1 Honda Pilot 2006 00-NONE 0.,. z j--_, DUE TO CRASH ❑ El 2 x ... 13-UNDER CARRIAGE 6 I ©). 2 FIRE ❑ ® U2 C c F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-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 6 I1:, 4 COM VEH ❑ ® U1 CO FIRST CONTACT 11 7�. _5 •If Yes.See Sidebar = ELGIN IL 60120 0 1 0 AW18006 IL 2026 AR C IL D 0 2HKYF18176H541918 PROGRESSIVE ❑Y ®N RDEF71 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Cardenas-Bernardino. Luis. M. 910851932 BAC $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = KNIT) (SEAT) (DM (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 N 1 ® 11 1 10,28 /2025 05 59 ®pm in a Work Zone? ®N DIRP co 1 F PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 5 C) T o� 2 ❑ 2 15 , , ❑PM ❑Construction * Z 3 ❑ lyg CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM ❑Maintenance U2 ® 1 1 1 0 Utility ARREST NAME PEREZ.TERESA 11-902 456-433(w) / ! El PM ' o U1 CITATIONS ISSUED PENDING SLMT o N SECTION CITATION NO. ROAD CLEARANCE TIME 0 AM F 2 ElARREST NAME 10 r 28 l2025 06 12 ®PM ❑Unknown work zone type U1 30 n T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 D 456-Romalo.Carmine 301 391-Jacobucci , / ❑❑PnMn Workers present? ®N U2 30 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 INDICATE NORTH combination):or —I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver r _ (example:shuttle or charter bus):or C L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O - i. } } } transporting employees in the course of their employment(example:employee X ,11, transporter-usually a van type vehicle or passenger car):or C L i. ..}----I. - } } 1 •4. Is used or designated to transport between 9 and 15 passengers,including the driver. (I)+ for direct compensation(example:large van used for specific purpose):or O . 1 I _ l I I 5. Is any vehicle used to transport anyhazardous material(HAZMAT)thatrequires Tm Nof To_Sca(e _ placarding(example:placards will be displayed on the vehicle). ;p - CARRIER NAME Z ADDRESS 0 C LL OErarr r w CITY/STATE/ZIP 0 MOTOR CARR.ID 0 Interstate 0 Intrastate 0 I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other ; _Y_ __1 - 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 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 Silver Silver 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