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HomeMy WebLinkAbout2025-00073135 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 0110 11111010011001 lI100 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004O28914 u, 1 U21 1 1 1 U1 2 U2 1 U, 1 1_12 1 U, 1 U2 1 1 11 U1 1 U211 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW ' Elgin Police Department ONE PERSON'S El5501-51.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash El AMENDED YR 2025I 2025-00073135 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME 217 N MCLEAN BLVD Elgin 02:13 SECONDARY CRASH 2 ® ❑ RELATED ❑Y ®N 11 12 2025 ❑AM ❑YES El NO U1 -< _ _ PRIVATE mo !day!yr ®PM FLOW CONDITION m COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n ❑ FT/MI NESW Kane HIT&RUN ❑Y ® N WITH VEHICLESOT, INVLD ® STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 Q83 DRIVER 0 PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑NIAV ❑!CV ❑DJ DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n 1 2 ! yr 13-UNDER CARRIAGE ©,I �:: FIRE 0 IE 10STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 14 U2 4 <<n M 2 SYTM IN ENGAGED4 ❑Y ®SNE❑UNK VEH. O AT CRASH O 99-UNKNOWN 9 16•TOP 3 *Detraction Value 9 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s ;il S 4 5 *II Yes.See Sidebar Ut COM VEH El 0 1 0 F. FIRST CONTACT 12 7,. __ Z Chicago IL 60632 0 1 0 185539F IL 2025 r' , TELEPHONE IL D 0 54DC4W1 D4PS200153 National General ❑Y Igl N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m co Elgin Fire Green Attic Isulatio 2019822120 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 21 (,0j N DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL ❑EWES O NUV 0 NOV ❑DV Yr !2 0 0 3 Honda Accord 2013 00-NONE 'o,� t2 c,�2 FIRE DUE o CRASH ® U2 2 C o 13-UNDER CARRIAGE c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X ❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S 1 S .t. 4 COM VEH ❑ ® Ut W F,,, FIRST CONTACT 6 O7 ,�=Q)OS •If Yes,See Sidebar C ELGIN IL 60123 0 1 0 FE36479 IL 2025 FIRST Si)0 IL D 0 1 HGCR2F52DA216239 American Freedom ❑Y ®N RDEF71 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Elgin Fire Same 12-2489791-00 SAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Provena St.Joseph RESPONDER U1 = (UNIT) (SEAT) (DOS) (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 ❑Y U2 Z u 1 ® 11 1 11 ,12 l2025 02 13 ®AM in a Work Zone? ®N DIRP co 1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C) Eri 2 0 28 03 11(12 (2025 02 19 ®PM 0 Construction * R 3 0 ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 z J 0 AM ❑Maintenance U2 a ® 11 1 ARREST NAME Hernandez.Jorge 11-601 1556000109 11,12 l2025 02 22 ®PM SLMT o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility t 2 El ARREST NAME 1 1(12 l2025 03 17 ®PM El Unknown work zone type U1 0 AM 3O 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30 1556-Sanchez.Jimena 601 397-Jones 12 ,02(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 k WI...0 9W ADDITIONAL UNITS FORMS. r ----r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z INot To Scale , 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer - c ` --I -' I. INDICATE NORTH combination):or —I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C i unit21 N - (example:shuttle or charter bus):or X 3. Is designed tocarry 15 or fewer passengers and operated a contract carrier 0 + i.I- I- --I.- --J. ill es pa g pe } } } transporting employees in the course of their employment(example:employee transporter-usually a van type vehicle or passenger car):or w ---_a 2t77W?EV 11ona7Aw 4. Is used or designated to transport between 9 and 15 9e including rC/t } } for direct com nation exam I lar a van used for s �cifice ur o ):or the driver, ' 1. Pe ( P 9 Pe P pose):or L L____a____. a t l. I 1 t 5. Is any vehicle used to transport any hazardous material(HAZMAT)thatrequires •u placarding(example:placards will be displayed on the vehicle). ,Zmt —1 CARRIER NAME Z ADDRESS w CITY/STATE/ZIP I 0 MOTOR CARR.ID 0 Interstate ❑ Intrastate W11aaMa109Ave , . , o I I T I ❑ Not in Comm./Govt. ❑ Not in Comm./Other 0 --- --1 - USDOT NO. ILCC NO. m XI Source of above z xi Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z own tank)? 0 Yes ® 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 ®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 Green Blue 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 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