HomeMy WebLinkAbout2025-00071331 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 4 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00401 7266
u, 8 U2 1 1 1 U116 U2 U, 1 U2 u, 1 u2 1 5 9 u, 1 U221 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY El$500 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 1
VEHICLE/PROPERTY ®OVER$1,500
El NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00071331 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
KENNETH CIR Elgin
® ❑ RELATED ❑Y ®N 11 02 2025 ®AM El YES El NO U1 -<
PRIVATE mo /day/yr 08:07 ❑PM FLOW CONDITION m
I 0 ® O COUNTY PROPERTY El 2�l N DOORING ICIy #OF MOTOR 0 SLOW 1 (n
!MI N S W Nicola Dr WITH VEHICLES INVLD 0 STOPPED U2 --I
El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Cook HIT&RUN IZ Y ElN PEDALCYCLIST®N ® FREE FLOW # LNS 0
18:DRIVER p PARKED 0 DRIVERLESS 0 PED CI PEDAL 0 EWES 0 NW 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
FOR DAMAGEDAREA(S) FROM TOWED U1 Q
NAME(LAST,FIRST,M) mo
1 9 8 7 T Ford Expedition 2020 00-NONE ,, •
12 , DUE TOCRASH 0 13-UNDER CARRIAGE FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 1U O 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 76•TOP 3 *Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ ;iI a �i COM VEH 0 Ea 1 0
~ ELGIN N I L 60120 0 1 0 FIRST CONTACT 1 7 . -_5 *II Yes.See Sidebar U1
Z EJ58226 IL 2026
TELEPHONE
IL D 1 FMJK2AT3LEA88581 Country Preferred Insuran ❑Y ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same P010204868 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER 73
73
Refused ❑Y ® N 2 0
p DRIVER X. PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 Nuy 0 NCv 0 Dv
yr 13-UNDER CARRIAGE -
10;i :., 2 FIRE 0 ElU2 C
I' SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR C)
a SYSTEM IN 0 ENGAGED 0 15-OTHER 9..16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 14 COM VEH D ® Ut CO
F,,, FIRST CONTACT 7 O7 .1 at 5,=5 •It Yes.See Sidebar
EP94401 IL 2026 REAR
0 N
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
1 GKEK63R5YR229444 National General ❑Y ®N RDEF 7)
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER I =
Sanchez-Corona.Salvador 2031289565 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (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 11 ,02 ,2025 08 07 ®❑PM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
o"
2 28 17 , ) 0 PM ❑Construction *
Z3 0 El CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 7
o 1 ® 11 1 ARREST NAME Ruano. Misty. N. 11-503-A-1 1547000157 , r El PM SLMT
•
I$!CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
o N AM15
r 2 ❑ ARREST NAME Ruano. Misty. N. 11-601-Ax 1547000156 , r DI PM ❑Unknown work zone type U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 15
1547-Steele.Justin 201 12 ,02,2025 09 00 ❑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----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 r -r -, r INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
z - } (example:shuttle or charter bus):or
X
s.,+remnner ar r r r
' A l A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier O
} } } transporting employees in the course of their employment(example:employee X
N transporter-usually a van type vehicle or passenger car):or
L �-----}----; I I NOt TO SCBfe - I. } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver, C
r r -:- '.. \ 1
Plait' — for direct compensation(example:large van used for specific purpose):or O
t l. I t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires :(I)
placartling(example:placards will be displayed on the vehicle).uxrs un�s
untr r r r r r CARRIER NAME Z
_ ADDRESS 0
C)
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
----------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
Black Black
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/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE