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HomeMy WebLinkAbout2025-00063490 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Df 2 Sheets 01111101111 I0110 1111 ,100 1111 lI1101111011 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X 015329' u, 1 U21 3 4 1 u, 2 U299 u, 1 U2 1 u1 99 U2 99 1 10 u, 3 U2 1 *P 0119�K 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 El$501-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and for Tow Due To Crash YR 2025I 2025-00063490 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1 S STATE ST Elgin05:29 ® ❑ RELATED 0 Y ®N 09 27 2025 ❑AM YES ®NO U1 PRIVATE mo /day/yr ®PM FLOW CONDITION m 1 0 r MI N E S W E Chicago St COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 cn ® 0 g Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 18:DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0 FOR DAMAGEDAREA(S) FROf tf�TOWED EN U1 0unknown.adriana Honda CRV 2008 00-NONE ©, >2 �/DUE TOCRASH ❑ NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 10.I 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED U2 4 < F 2 4 SYSTEM IN O ENGAGED 0 15-OTHER 916.70P 3 ® ❑ _ ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 9 ALGN r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s it 6 �i COM VEH 0 Ea 2 O 1 0 1 0 FIRST CONTACT 11 7_: __5 *II Yes.See&debar U1 Z DN18917 IL 2025 REAR TELEPHONE IL D 5J6RE48598L802552 State Farm ❑Y Igl N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Olivares Huerta. Maria. D. 0702359-SFP-13 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ® N 2 As �{ DElVER 0 PARKED 0 DRIVERLESS ❑ KO 0 PEDAL 0 EWES 0 NIAV 0 Ncv 0 DV 1 9 yf 6 Hyundai PALISADE 2024 00-NONE „ ` 12 "_, DUE TO CRASH ❑ 2 x o 13-UNDER CARRIAGE FIRE 0 ® U2 Po F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 016-TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistractlon value 9 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF O I .,.4 COM VEH ❑ ® U1 W FIRST CONTACT 9 O7 j_,__s •(ryes.See Sidebar C Prospect Heights IL 60070 0 1 0 H756670 IL 2026 "E 4 N Z IL D KM8R7DGE1 RU731503 Allstate ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same 974600835 BAc $ 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) 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 1 09,27 /2025 05 29 ®AM in a Work Zone? NJ o1RP > 1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 2 C1 v T 2 ❑ 2 28 / / ❑PM ❑Construction * Z 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 -a, ARREST NAME / / ❑PM ' I ® 1 1 1 0 CITATIONS ISSUED ❑PENDING • UtilitySLMT o N SECTION CITATION NO. ROAD CLEARANCE TIME 0 0 AM t 2 ElARREST NAME 09!27 12025 05 39 ®PM ElUnknown work zone type U1 35 n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 0 Y 35 1525-NavE.Oscar 601 - ! r ❑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 0 . ADDITIONAL UNITS FORMS. r ----r•---, , 1N7C logla8t - . 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----4. Not To Scale 1 - !' INDICATE NORTH combination):or —I p1 \ \ BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C 0 r r (example:shuttle or charter bus):or X 3. Is designed to carry15 or fewer passengers and operated I a contract carrier O - <_----- --i-- ` \ \ - } } } transporting employee � �In the course of their employment(example:employee X transporter-usually a van type vehicle or passenger car):or w -- - I. } } 1. 4. Is used or designated to transport between 9 and 15 passengers,including the driver. N •for direct compensation(example:large van used for specific purpose):or O \tom } } } _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D . placarding(example:placards will be displayed on the vehicle). XI a'A i CARRIER NAME Z \.'' \ 0 yp ADDRESS �% D g CITY/STATE/ZIP \ \ i. i. T- i. MOTOR CARR.ID 0 Interstate 0 Intrastate 5 1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other 0 - USDOT NO. ILCC NO. C m XI Source of above 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 Blue 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/TO. DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE