HomeMy WebLinkAbout2025-00071210 (2) ILLINOIS TRAFFIC CRASH REPORT Sheet 3 of 6 Sheets _ Mil III 11 111111
DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY
U110 U21 2 4 1 U1 1 U2 1 U1 1 U2 1 U1 1 U2 1 1 15 U121 U221 *P 0119*
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
❑AMENDED YR 2025I 2025-0007121 O VEHT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 �I
N MCLEAN BLVD Elgin 04:08
® ❑ RELATED ®Y 0 N 11 01 2025 DAM ®YES 0 NO U1 -<
g PRIVATE mo /day/yr ®PM FLOW CONDITION M
FT N E S W LAWRENCEAVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR IRSLOW 1 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
0 DRIVER N PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
/ / FOR DAMAGEDAREA(S) FROM TOWED U1 0
Toyota Tundra 2005 00-NONE 0• >2 i 0 DUE TO CRASH ❑ EN
NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 10 1 2 FIRE 0 ig
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 23 U2 2 rn
SYSTEM IN O ENGAGED 0 15-OTHER 916.TOP 3 _
❑Y (Z/N ❑UNK VEH. AT CRASH 99-UNKNOWN a 4 `Detraction Value 9 ALGN
F
CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FRISTNTOONTACT 12 Y Tallk._s CO ir MBSeeSideDar VEH ❑ )� Ut 1 0
0
Z 3688898B IL 2026
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 11/
0 5TBBT44165S461761 Allstate ❑Y ®N U2 m
5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Velazquez.Julio.C. 811871918 1 1-
5 HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
r RESPONDER
( ou
5, 0 DRIVER N. PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 uv 0 NCV 0 Dv
yr Q,_
o _ 13-UNDER CARRIAGE 10,i I.. 2 FIRE 0 ® U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR 0
SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP 3 9 0
a ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistracuon Value
POINT OF s (�{ 4 U1
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 12 7, B `6 C.OMy VEH
® C
CO
H FA11798 I L 2025 I 0 Si)
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O
0 1J4GL48K33W653243 American Heartland Insura ®Y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Reyes.Charlizie.Y. AHQ0039094 BAG $
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)
2 4 04 /
0 O
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 El 11 1 11 ,01 /2025 04 08 ®AM in a Work Zone? ®N DIRP co
PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 3 0
T 2 0 11/01 /2025 04 30 PM
® • ❑Construction >F
1 4
R 3 0 ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME J
❑AM ❑Maintenance U2
-a, ARREST NAME Rubio Gonzales. Miranda 6-303-A 752389 11/01 /2025 04 35 Igi pM SLMT
o N 1 ® 11 1 igi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM 3O
• ❑Utility
t 2 0 ARREST NAME Rubio Gonzales. Miranda 3-708 752390 1 1/01 /2025 05 31 ®PM 0 Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y
2 3 0 25
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.
0 A CMV is defined as for vehxae used to tra and:
r ----,5-••--, ; any mo nsport passengers or property
Z
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -
} }-- -;-- --; } } } r -, , ; ; , 1, ( combination):or —I
INDICATE NORTH X1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ' J. , } (example:shuttle or charter bus):or
X
3. Is
. L.___A_. 1 i. <--_... . J transporting edmployeeslin5 hecourseeo theire rsmployment exam pal
e:employeener 73} } }
• � . transporter-usually a van type vehicle or passenger car):or co
< <.__-a-_-_, , < .---_-a-___� , J. , , 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or 0
L L___-a____.I L L L ...._-..i._ 1 t i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). XI
--I
CARRIER NAME Z
i.
ADDRESS 0
th
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other O
USDOT NO. ILCC NO. m
73
Source of above z
) ❑ Side of Truck [0 Papers 0Driver ❑ Log Book m
Z
GVWR/GCWR 1
El <10,000 0 10,000-26,000 0 >26,000 z
Were HAZMAT placards on vehicle? 0 Yes 0 No =
If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. P3
XI
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
73
IDOT PERMIT NO. WIDELOAD-; ❑Yes 0 No 2
TRAILER VIN 1 m
to
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 3 COLOR U 4 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Maroon Black
u 3 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 4 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE