HomeMy WebLinkAbout2025-00071210 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 6 Sheets 01111101111 10110 ll 1111 fl 10 00 I 0
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XO04018241
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 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$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 2025I 2025-0007121 O VEHT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
N MCLEAN BLVD El In04:08
® ❑ RELATED ®Y 0 N 11 01 2025 ❑AM Ea YES 0 NO U1
g PRIVATE mo !day/yr ®PM FLOW CONDITION ITl
•FT N E S W LAWRENCEAVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 1 cn
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 NUV 0!CV 0 DJ DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
0 5 !
yr
13-UNDER CARRIAGE 10 12 FIRE 0 ® <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 ]$I U2 rr1
F 2 8 ❑Y ®SYSNEM IN n❑UNK VEH. AT CRASH 99-UNKNOWN 9 16•TDP�3 `Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s ii_B I,,4 COM VEH 0 Ea 1 0
~ ELGIN IL 60123 0 1 0 FIRST CONTACT 3 7_; _-5 *!rves.see sidebar U1
Z FM11034 IL 2025 E
TELEPHONE
IL D 0 1 GYS4BEF3BR103895 NA ❑Y ❑N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same NA 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER
/1 9 8 5 Infiniti QX60 2016 00-NONE a.FOR DAMAGEDAREA(S) FR0! 0 DUE TO CRASH rg ❑ 2 x
_y Yr 13-UNDER CARRIAGE 10) 12 FIRE 0 ® U2 C
❑Y ®N DUNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value ❑ 9 ® U1 0 CO
POINT OF 8 i CC ``.. 4 COM VEH N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 12 7 �I�.5 •It Yes.See Sidebar
= Elgin IL 60123 0 1 0 CW31589 IL 2026 I 0 N
IL 0 5N 1 ALOM MXGC513270 Allstate ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Elgin Fire Same 811383307 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 176 <
Refused RESPONDER
U1 I
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS)+(TELEPHONE) (EMS) (HOSPITAL)
1 3 11 /
4 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 ,01 /2025 04 08 ®AM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7CI
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 ® 18 1 19 23 11,01 ,2025 04 30 PM
® • 0 Construction *
en
R O 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
3 ❑AM ❑Maintenance U2
-a, ARREST NAME Rubio Gonzales. Miranda 11-1204-B 748260 1 1,01 ,2025 04 35 Igi pM SLMT
o N ER 11 1 ISICITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM30
• 0Utility
t 2 0 ARREST NAME Rubio Gonzales. Miranda 3-707 748259 1 1,01 ,2025 05 31 ®PM 0 Unknown work zone type U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1549-Brown. Bryan 602 11 , 19,2025 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••--, , .iI e ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
r l j 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
ism c 'f _r -' s INDICATE NORTH combination):or —I
trt
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
� i = _ (example:shuttle or charter bus):or 0
AMA
- ------ ----; 3. Is sportng err ned o car slln the fewer
r pass pe ershand o ent exampleontract carrier I °
} } } pb
_! transporter-usually a van type vehicle or passenger car):or w
__ -- �1ntt 1 - t I- t •4. Is used or designated to transport between 9 and 15 passengers,including the driver. C
TLI for direct compensation(example:large van used for specific purpose):or
N7Mc1ean7Bhrd -D
l. I• 1 _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
s:. _ placarding(example:placards will be displayed on the vehicle). ;p
A I . ' ) --
i I Unit 2— — — CARRIER NAME Z
0ADDRESS
• CITY/STATE/ZIP7411111 —N�
_ MOTOR CARR.ID Interstate Intrastate
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Not in Comm./Govt. Not in Comm./Other0
Not To Scale
USDOT NO. ILCC NO. m
XI
Source of above z
. If Yes,Name on placard 0
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
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. 0
White Black
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE