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HomeMy WebLinkAbout2025-00070978 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I0110 II II 100 00 lI EE II I 0 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00401 5332' u, 1 U21 3 4 1 U1 5 U2 1 U, 1 1_12 1 U, 1 U2 1 1 10 u1 3 U2 4 *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-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00070978 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn N STATE ST Elgin03:41 ® ❑ RELATED ' V 0 N 10 31 2025 ❑AM YES ®NO U1 —< _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m FT N E S W WEST RIVER RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR IR SLOW 1 (/)❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEOAL 0 EWES 0 NIAV 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n FOR DAMAGEDAREA(S) FROf tf TOWED U1 Q NAME(LAST,FIRST,M) mo 2 0 0 0 Chevrolet Camaro 201 7 00-NONE „. DUE TO CRASH ❑ VI Q0 13-UNDER CARRIAGE 19 i 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 4 (<Tl M I 2 SY4 ❑Y ®SNE❑UNK VEH. 0 AT CRASH M IN D 0 99-UNKNOWN 9 16•TOP 3 `Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8,_i� s �i COM VEH 0 j$J 1 0 ~ ELGIN IL 60123 0 1 0 FIRST CONTACT 1 7 ; __5 *IIYes.SeeSidebar U1 Z CA62553 IL 2022 Ismi TELEPHONE IL D 0 1 G 1 FE1 R77H0157868 State Farm ❑Y Il N U2 I' in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same 0813919-SFP-13 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ❑ N 2 0 p; DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 MAV 2 0 0 6 Honda Odyssey 2016 00-NONE al z j--_, DUE TO CRASH ❑ I1 2 ... 13-UNDER CARRIAGE 9 I ©Ic 2 FIRE 0 ® U2 C c F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 X ❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istraglon Value 9 U1 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-iI�1:, 4 COM VEH D ® co FIRST CONTACT 11 7 _, _5 ••If Yes.See Sidebar — Wauconda IL 60084 0 1 0 CM60954 IL I C 0 cn Z IL D 0 State Farm ❑V ®N RDEF71 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Crismariu.Aida.A. 0343527-SFP-13 BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) U2 996 r m ##occs y 71 / ,, U1 1 D 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 4 10,31 ,2025 03 41 ®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 ❑ 06 99 / , ❑PM ❑Construction * R 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 ❑AM ❑Maintenance U2 a ® 11 4 ARREST NAME Nava.Alejandro 11-801 1532-662 / r ❑PM SLMT o Nu • ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility 45 t 2 ❑ ARREST NAME AM 7 1 r ❑❑PM ❑Unknown work zone type U1 % 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 45 1532-Hernandez. Daniel 501 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 -< c ` --1 -' r INDICATE NORTH combination):or —I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C _ } (example:shuttle or charter bus):or X L A 3. Is desgned to carry 15 or fewer passengers and operated by a contract carrier I O } } } transporting employees In the course of their employment(example:employee X L ----------+ — iii>(,.. - 1 } } •transporter sed or des gnated to transport between 9 and 1 passengers,including the driver, w C for direct compensation(example:large van used fors specific purpose):or L i I. i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D placarding(example:placards will be displayed on the vehicle). m 0 t t - -I CARRIER NAME Z 1 ~ ADDRESS ' 1 ;41r-,--- i. CITY/STATE/ZIP 0 Not To Scala j MOTOR CARR.ID 0 Interstate ElIntrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other ; _Y_ __1 - USDOT NO. ILCC NO. m XI Source of above z ' . MCS 0 Yes 0 No 0 Unknown Out of Service 0 Yes ❑No 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 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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO. DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE