Loading...
HomeMy WebLinkAbout2025-00071816 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 6 Sheets 01111101111 I0110 1111 101001fl 111 III 0 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004025O62 u, 2 U2 1 1 1 U, 4 U2 1 U, 1 1_12 U, 1 U2 1 4 9 U1 1 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 ❑5501-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) (8:1B Injury and for Tow Due To Crash 0 AMENDED YR 202512025-00071816 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 m ® ❑ RELATED ®Y 0 N 11 05 2025 ®AM ❑YES ®NO U1 WAVERLY DR Elgin01:36 _ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m FT/MI MI N E S W S WAVERLY CT COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR IR SLOW 3 Cl) ❑ Cook HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0 Q83 DRIVER O PARKED O DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C) 0 8 ! yr 13-UNDER CARRIAGE © !. 2 FIRE ❑ alC STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED ❑ 0 U2 m M 2 5 ❑Y ®SNEM❑ 15-OTHER UNK VEH. O AT CRASHD O 99-UNKNOWN 9 76-TOP 3 *Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s,_iL B 4 COM VEH 0 j$J 1 0 ~ ELGIN N I L 60120 0 1 0 FIRST CONTACT 12 7 ; _5 *Irves.See Sidebar U1 Z FL44498 IL 2026 REAR 7 TELEPHONE IL D 0 5N 1 ED28Y9YC503807 Progressive Ely ®N U2 m 5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same 861379526 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ❑ N 2 0 0 DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 m/v 0 i v 0 Dv yr Chevrolet Astro Van 1994 00-NONE al z j--_, DUE TO CRASH 0 ❑ 2 x o 13-UNDER CARRIAGE I ©Ic 2 FIRE ❑ El U2 C SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 ® SPDR C) SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 0 CZ ❑Y NJ ❑UNK VEH. AT CRASH 99-UNKNOWN *0istraci n Value POINT OF 8 4Ut N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 12 7 -4 C•IOMs VEHeeSidecar❑ ® CO H 3223407B IL 2026 RE 0 N M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 1 GBDM15ZORB136203 State Farm ❑Y ®N RDEF71 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Baeza. Miguel 3057064-SFP-13 BAG E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = iUNIT) (SEATI (DOB) (SEX) {SAFT) (AIR) (INJ) (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 0 Y U2 Z N 1 ® 18 1 11 ,05 l2025 01 36 ®❑PM in a Work Zone? ®N DIRP co I I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 o" 2 ❑ 08 28 1 , ❑PM ❑Construction * Z 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM ❑Maintenance U2 -a, ARREST NAME Chavez. Eddy 6-20-E 747868 / ! ❑PM o U 1 ® 1 1 1 ❑Utility CITATIONS ISSUED 0 PENDING SLMT SECTION CITATION NO. ROAD CLEARANCE TIME o N t 2 ❑ ARREST NAME Chavez. Eddy 11-601 747865 11 r 05 /2025 03 00 MAM PM ❑Unknown work zone type U1 25 n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ ®Am Workers present? 25 1520-Gutierrez.Jovani 202 331-Ziegler 12 , 15,2025 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••--, , ; 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 -< } } ' ' I ® r INDICATE NORTH combination):or p0 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver i _ I - } (example:shuttle or charter bus):or . 'AA I , 3. Is designed to carry 15 or fewer passengers and operated a contract carrier I O - <_----- i - . ---- �..e - } } } transporting employees in the course of their employment(example:employee X transporter-usually a van type vehicle or passenger car):or w Q. L 4. Is used or designated to transport between 9 and 15 passengers,including C�-----;----; - - •} } } g po passen rs,indudi the driver, 40 for direct compensation(example:large van used for specific purpose):or O I- <____a____. It i } } t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)thatrequires placardingrn(example:placards will be displayed on the vehicle). ;p CARRIER NAME Z ADDRESS 0 V) ...na CITY/STATE/ZIP 00 Not To Scale . - i. i. i. 4. MOTOR CARR.ID 0 Interstate 0 Intrastate . I . . ❑ Not in Comm./Govt. 0 Not in Comm./Other --'--------1 - USDOT NO. ILCC NO. rn XI Source of above z 0 Yes 0 No ❑ Unknown 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' m TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Red Green 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