HomeMy WebLinkAbout2025-00069887 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY MD4011208.
u, 9 U29 1 1 1 U1 99 U2 1 U199 U299 U, 1 U2 1 4 9 U123 U221 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
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 ❑ B Injury and/or Tow Due To Crash YR 202512025-00069887 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 71
1149 MEADOW LN Elgin05:38
® ❑ RELATED ❑Y ®N 10 26 2025 ®AM ❑YES El NO U1 —<
PRIVATE mo /day/yr ❑PM FLOW CONDITION IT1
_
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 1 (n
❑ FT!MI N E S W Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD ❑ STOPPED U2 -I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Q83 DRIVER O PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
! ! FOR DAMAGEDAREA(S) FROPtf TOWED U1 O
Unknown.0. Chevrolet Express 2017 00-NONE „ 12 , DUE TO CRASH ❑ EN
NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 'Irv.
!�. 2 FIRE 0
IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED U2 2 <
9 3 SYSTEM IN 9
❑Y ❑N ®UNK VEH. AT ENGAGED CRASH 9 15-OTHER
99-UNKNOWN 9 16.TOP 3 ❑ _
`Distraction Vatuc 7 ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ iI s li 4 COM VEH 0 1� 1 0
~ 0 1 0 FIRST CONTACT 6 7_;LQ--5 *If Yes.See Sidebar Ut
Z 2105153B IL 2025 E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 I-
1 GCWGAFF9H 1133191 Stonegate ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Brindis Espino. Miguel ILCA7GD3LR0000 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF`Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
r D Y°®N ( G0)
❑ DRIVER I} PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 M/v 0 NO! 0 DV CIRCLE NUMBER(S) U1
yr Honda Civic 2012 00-NONE Q-i, 12..__t DUE TO CRASH ❑ ® 1 X1
Ti 13-UNDER CARRIAGE 9) c 2 FIRE 0 El U2 C
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR n
SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 9 0 X
a ❑Y ❑N DUNK VEH. AT CRASH 99-UNKNOWN *Distraction Value
POINT OF 8 4 Ut
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 10 7-. S i's C•OM
See Sidebar ® co
H BC40407 I L 2025 REAR 0 N
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
2HGFB2F90CH516446 Geico ❑Y ®N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Clarke. Phillip.A. 4491229151 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
{UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
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 10,26 /2025 05 38 ®❑pM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
2 0 30 99
N 3 0 ❑CITATIONS ISSUED 0 PENDING + ❑PM• El Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 3
—a, ARREST NAME / / El PM '
I ® 1 1 1 ❑CITATIONS ISSUED ❑PENDINGUtilitySLMT
NNO. ROAD CLEARANCE TIME
o ❑
SECTION CITATION
AM u, 30
t 2 0 ARREST NAME 10 r 26 12025 05 38 [0 PM 0 Unknown work zone type
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 1563-Rodriguez.Carlos 501 331-Ziegler , , ❑❑PM 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 -<
c ` --I -' r INDICATE NORTH combination):or .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- } (example:shuttle or charter bus):or
X
•-- •
0 3. Is designed to carry15 or fewer passengers and operated I a contract carrier O
I- -- ---- --i ,,...�...,.. ,.,,r...,.., a,mm,r..n. - } } } transporting employee � �In the course of their employment(example:employee X
or
...I. I I L I I Not To Seale transporter. sed or des gnated to translly a van type port betweeicle or n 9 and 15enger rpa passengers,including the driver,
—J J J \ w
C
— - } } for direct compensation(example:large van used for specific purpose):or 0
L L____a____. �, :I - 5. Is any vehicle used to transport anyhazardous material(HAZMAT)thatrequires m
placarding(example:placards will be displayed on the vehicle). ;p
. 1
CARRIER NAME Z
„w.rr..n. n..rrr...w. a"s"°.w"" - __ ADDRESS 0
C)
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
. I . . ❑ Not in Comm./Govt. 0 Not in Comm./Other
-----------1 - USDOT NO. ILCC NO. rn
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
co
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
White Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE