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HomeMy WebLinkAbout2025-00071995 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111 0110 1111 flIII 1010111111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004018189` u, 1 U21 3 4 1 U116 U2 1 u, 1 1_12 1 u, 1 U2 1 5 9 u, 1 U221 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW ' Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 14 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash 0 AMENDED YR 2025I 2025-00071995 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn S GIFFORD ST Elgin09:06 ® ❑ RELATED ❑Y ®N 11 05 2025 12— ❑YES El NO U1 -< _ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION m FT!MI N E S W VILLA ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR IR SLOW 1 (n ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0 Q83 DRIVER O PARKED E DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 02 n .FROM TOWED U1 Butler.Calvin. P. BMW 535 2016 00-NONE ©1 Q2 F 01 DUETOCRASH ® 0 E NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 10 1 2 FIRE 0 IE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 02 m M 2 8 ❑Y ®N SYSTEM ❑UNK VEH. O AT CRASHD O 99-UNKNOWN 9 16•TOP 3 *Distraction Value 5 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF & i�S 4 COM VEH 0 1 O " �- SOUTH ELGIN IL 60177 0 1 FIRST CONTACT 12 T ; _s *IIYes.SeeSidebar U1 Z 526AC982 IL 2026 TELEPHONE IL D WBA5B3C51 GG255652 AAA ❑Y ®N U2 m .5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same AUT702333041 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER XI Refused 0 Y ® N 2 0 0 DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMy 0 NCV 0 DV CIRCLE NUMBER(S) U1 yr ,a 12 c 2 FIRE 0 El U2 C Ti 13-UNDER CARRIAGE ' SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP3 0 ® SPDR n ❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN *0istrac on Value 9 U1 9 - POINT OF 8 I -4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR S COM VEH ❑ ® CO F,,, FIRST CONTACT 6 O7 ,�=QI OS •IfYes See Sidebar C EV24558 IL 2026 aR 0 N M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 2C3CDXJGOFH791435 SAFEWAY ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 RAMIREZ LOPEZ. DENIS. E. 4143579-IL-PP-002 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) OM (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0 EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z u 1 ® 18 1 11 ,05 l2025 09 06 ®PM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 � 0 1 2 0 41 28 I ! 0 PM ❑Construction >F R 3 0 I!!I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM 0 Maintenance U2 oD El 11 1 ARREST NAME Butler.Calvin. P. 11-601 1506-465 ! ! El PM SLMT o N 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility 25 t 2ARRESTNAMEAM 7 ❑PM 0 Unknown work zone type U1 El 1 / ❑ n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑Y 25 1506-Nunez. Maria 301 - r ! El 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 INDICATE NORTH ___-; N combination):or —I p1 NIT 1 II BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C (example:shuttle or charter bus):or 0 Not To Scale I 3. Is designed tocarry 15 or fewer passengers and operated a contract carrier O L �_---------i esg pa g pe , P0.1. } } } transporting employees in the course of their employment(example:employee � X transporterusually a van type vehicle or passengercar).or co L i. __}----; - I. } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver. N for direct compensation(example:large van used for specific purpose):or L L____a____. i i UNIT2 _ t _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D ' placarding(example:placards will be displayed on the vehicle). XI —I CARRIER NAME Z vii isr . _ ADDRESS 0 w 0 CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate 0 Intrastate 1 I r 1 . ❑ Not in Comm./Govt. 0 Not in Comm./Other 1 1 --11 I r , USDOT NO. ILCC NO. < xi Source of above Z . ❑ Yes 0 No 0 Unknown g D Did Carrier Safety Regulations MCS)violation contribute to the crash? A ❑ Yes No ❑ 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'; 0 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 Black Blue u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO: _ . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE