HomeMy WebLinkAbout2025-00071504 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004016049*
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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 ❑$501-S1,500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 2025I 2025-00071504 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 m
® ❑ RELATED ®Y 0 N 11 03 2025 NAM ❑YES ®NO U1
N MCLEAN BLVD Elgin06:59
_ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FT l MI N E S W BIG TIMBER RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ® FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C)
FOR DAMAGEDAREA(S) FRO'1T TOWED U1 Q
Gutierrez.Sandra 0 4 /
yr 13-UNDER CARRIAGE 10 , 2 FIRE ❑ IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 0 m
F 2 4 ❑Y ® 15-OTHER
SYSTEM
❑UNK VEH. 0 AT CRASHD 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, it 6 4 COM VEH 0 j$J 1 0
" �- GILBERTS LBERTS I L 60136 C 1 FIRST CONTACT 12 7 ; _5 *II Yes.See Sidebar U1
Z BM40113 IL 2025 ' E
TELEPHONE
IL D 0 STDJZRFH9HS377169 State Farm ❑Y N N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 0199 591 SFP 13 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 2 0
m x DRIVER ❑ PARKED ❑DRIVERLESS 0 PEO ❑PEDAL 0 EWES ❑NMv 0 KCV ❑DV CIRCLE NUMBER(S) U1
!2 0 0 9 Chevrolet CJK 1500 2011 00-NONE ,�__' 12...�DUE TO CRASH ❑ 2
0y Yr 13-UNDER CARRIAGE 10 z FIRE ID El U2 C
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F 2 4 SYSTEM IN 9 ENGAGED 9 15-OTHER 9,16-TOP 3 X
❑Y ❑N N UNK VEH. AT CRASH 99-UNKNOWN *0istraellon Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s-it 6 1l, COM VEH El U1 CO
FIRST CONTACT 1 Y _, _6 •(ryes,See Sidebar
= ELGIN aR
C
IL D 0 3GCPKSE32BG370131 Progressive ❑Y N N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Same 987582921 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPOND
0 N u1 =
(UNIT) (SEAT) IDOBi (SEX) {SAFT) (AIR) (INJ) 1(EJCT( (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
1 3 05 /
:A
/ / UI 3 m
/ / 1 0
EV MOST EVNT LOC, DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 1 11 /03 /2025 06 59 ®❑pM in a Work Zone? ®N DIRP co
1 t 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 0 25 28 / ! 0 PM ❑Construction *
Z3 0 N CITATIONS ISSUED PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 7
a ® 11 4 ARREST NAME Gutierrez.Sandra 11-305 260-01775 / ! ❑PM SLMT
o N
0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
30
F 2 ARREST NAME AM
7 / / ❑❑PM 0 Unknown work zone type U1
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OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 - ❑AM Workers present? ❑Y 30
260-Sheehan.Joseph 502 / / ❑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 -<
- }__-_r-_--; _ combination):or
Not To Scale INDICATE NORTH p3
. BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
L I I } (example:shuttle or charter bus):or
d I I 3. Is designed to carry 15 or fewer passengers and operated a contract carrier 0
}} } transporting employees In the course of their employment(example:employee
13e7 F transporter-usually a van type vehicle or passenger car):or w
L L.___a____.l rI. } 4. Is used ordesinatedtotrans rtbetween9and15passengers,includingthedriver,
C
} } for direct compensation(examp:large van used for speific purose):or
-- j _ t i. i. t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
•p
j , placarding(example:placards will be displayed on the vehicle). D
♦ CARRIER NAME Z
M1 0
ADDRESS
r I I 0 n
CITY/STATE/ZIP 0
I I I `I I N•7 n. - MOTOR CARR.ID 0 Interstate 0 Intrastate
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
----------1 - USDOT NO. ILCC NO. m
XI
Source of above z
Form Number m
Xl
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
to
LOCAL USE ONLY TRAILER VIN 2 m
a
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
Gray White
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT' 2 TOWED BY/TO.
Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE