HomeMy WebLinkAbout2025-00071671 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 1 0110
1111
ill 1110111111*
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X�018188
u, 1 U21 2 4 1 U, 2 U2 1 U, 1 1_12 1 U,99 U2 1 1 15 U1 1 U2 1 *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 2
VEHICLE/PROPERTY ®OVER 51,500 ®NOT ON SCENE(DESK REPORT)
El AMENDED ElB Injury and/or Tow Due To Crash YR 202512025-00071671 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED ®Y 0 N 11 04 2025 ®AM ❑YES ®NO U1 -<
SUMMIT ST Elgin06:49
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FTlMI N E S W PRESTON AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD DO
U2 —I
lgi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑NW ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
FOR DAMAGEDAREA(S) FM TOWED U1 Q
RO
Castro.Jose.A. 1 2
yr 13-UNDER CARRIAGE
10
EN
I , 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 4 rn
M 2 4 ❑Y ❑SNE®UNK VEH. 9 ATCRASHD 9 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 �i COM VEH 0 ix) 1 C)
4
1— FIRST CONTACT 11 7__ --_11__5 *IIYes.See Sidebar U1 0
Z ELGIN IL 60120 0 1 0 EB11123 IL 2026 REAR
TELEPHONE
IL D 0 1 C3CCBBG 1 DN660197 First Chicago Insurance C ®Y ❑N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
Castro.Arlene, I. 1131520-00 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 ou
m �{ DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑NMV 0 NCV ❑Dv
y 2 0 0 2 Volkswagen Jetta 2024 00-NONE 1�_' 12...0 DUE TO CRASH ❑ C 2
Yr
.. 13-UNDER CARRIAGE 10 2 FIRE 0 El U2 C
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-it 6 Il, U1 COM VEH ❑ ® W
FIRST CONTACT 1 7�' -5 •If Yes.See Sidebar
1...
Wauconda IL 60084 0 1 0 FA81777 IL 2025 REAR 0 N
M
IL D 3VW7M7BU3RM096533 State Farm ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
Gibson.Adna,C. 0943770-SFP-13 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)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 4 11 ,04 ,2025 06 49 ®❑PM in a Work Zone? ®N DIRP co
1 r PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 5 n
T
ai
2 ❑ 2 99 + ) ❑PM ❑Construction *
R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM ❑Maintenance U2
a ® 11 4 ARREST NAME Castro,Jose,A. 3-707 1508000785 , r El Pm SLMT
I$!CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility
8 N ❑AM 35
r 2 El ARREST NAME Castro,Jose•A. 6-303-A 1508000784 , r ❑PM 0 Unknown work zone type U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 35
565-Villagomez, Mireya 202 12 , 18,2025 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
- / a ADDITIONAL UNITS FORMS.
Not r ----r••--, , +� To Scale //�� A CMV is defined as any motor vehicle used to transport passengers or property and: Z
�71'� 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
i- `-----I-----' N - r INDICATE NORTH combination):or -I
' ;i. U 1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
, ter.
1 al`# _ i. (example:shuttle or charter bus):or 0
,9i'
Is designed to carry 15 or fewer passengers plo operated by a contract career I O
} } } transporting employees In the course of their employment(example:employee X
__ transporter-usually a van type vehicle or passenger car):or co
L L.___a____� 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including N
• •� } } } for direct com nation exam I lar a van used for s cific ur o ):or the driver,
_ ones
' Pe ( P 9 Pe P Pose):or
L L--_-a-___.I - 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
D_ _
CARRIER NAME Z
I
I - ADDRESS O
D
CCITY/STATE/ZIPng
MOTOR CARR.ID 0 Interstate 0 Intrastate
...) 1
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
- " USDOT NO. ILCC NO.
m
XI
Source of above 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. 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?
❑ Yes II No ElUnknown A
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
v
TRAILER WIDTH(S) 0-96" 97-102" >102' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
White 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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE