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HomeMy WebLinkAbout2025-00072696 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Df 2 Sheets 01111101111 I0110 1111 1010011111000 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004025O55 u, 1 U21 3 4 1 U1 4 U2 1 U, 1 1_12 1 1.11 1 U2 1 1 11 U1 15 U2 11 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 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 3 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) El AMENDED ElB Injury and for Tow Due To Crash YR 202512025-00072696 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ® ❑ RELATED PRIVATE ®Y 0 N 11 10 2025 ®AM ❑YES ®NO U1 -< KI M BALL ST Elgin mo /day/yr 08:40 ❑PM FLOW CONDITION III 0100 /MI N E S © North Grove Ave COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 u) Kane HIT&RUN ❑V ® N WITH VEHICLESOT, INVLD ® STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS O 18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n FOR DAMAGEDAREA(S) FRO T TOWED U1 Q Gonzalez-Briceno. Mil s C. 03 / yr 13-UNDER CARRIAGE 1a.I 2 ' 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 4 I<n F 2 SY 15-OTHER 4 ❑Y ®SNE DUNK VEH. 0 AT CRASH M IN D 0 99-UNKNOWN 9 76•TOP 3 *Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 7 :il S 4 COM VEH 0 j$J 1 0 ~ ELGIN IL 60120 0 1 0 FIRST CONTACT 12 7_; _5 *Irves.SeeSidebar U1 Z ER50761 IL 426 E TELEPHONE IL D 0 1HGEM22545L048171 Unique ❑Y ®N U2 m in m EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR --1 Same ILP2835274 4 I— `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER en Refused ❑Y ® N 2 0 m x DRIVER 0 PARKED 0 DRIVERLESS 0 RED 0 PEDAL 0 EWES 0 NMv 0 NO! 0 DV CIRCLE NUMBER(S) U1 1 9 6 9 Subaru Outback 2014 00-NONE ,�_-1 12--_, DUE TO CRASH 0 C 2 o 13-UNDERCARRIAGE ta;l 2 FIRE ❑ ® U2 C c F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP 3 X ❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value 9 3 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s iI 4- 5 �' COM VEH D ® U1 W Y_ FIRST CONTACT 6 _{_Os•_5 •IfYes,SeeSidebar — Rockford IL 61108 0 1 0 Q115808 IL 626 REAR 0 N Z IL D 0 4S4BRCLC9E3297471 Allstate ❑Y ®N RDEF71 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same 975 058 615 BAC $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER u1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 1 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 ,10 i2025 08 48 ®❑PM AM in a Work Zone? ®N DIRP D co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 o" 2 0 28 11 ) ) 0 PM ❑Construction * R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM 0 Maintenance U2 oER 11 1 ARREST NAME Gonzalez-Briceno. Marielys.C. 11-601 254001601 / ! ❑PM SLMT o N 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility 30 r 2 0 ARREST NAME AM 7 1 r ❑❑PM 0 Unknown work zone type U1 % 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 0 AM Workers present? ❑Y 30 254-Henke. Robert no 275-Engelke 12 , 91 ,025 01 30 ®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 —I 0 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C (example:shuttle or charter bus):or n 3. Is designed to car 15 or fewer passengers and operated a contract carrier 0 -- I - } } } transporting employees in the course of their employment(example:employee X litlit.. I L transporter-usually a van type vehicle or passenger car):or CO i_ i. .J.,.. } } 1 •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 O L L____a____.I ) L i L i 5. Is anyvehicle used to transport anyhazardous material(HAZMAT)that requires 'D Mvoae,ra placarding(example:placards will be displayed on the vehicle). ,Zmt „� _ __ eta��a—� t>� — — CARRIER NAME Z _J ED 1103 Ell tiic 0 i ADDRESS D w AWt'♦b Scale I CITY/STATE/ZIP 0 g MOTOR CARR.ID 0 Interstate 0 Intrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other ; _Y_ __1 - USDOT NO. ILCC NO. m XI Source of above z . 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? 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. w Silver Tan u 1 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 2 DUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE