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HomeMy WebLinkAbout2025-00073157 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 mil 11 1111 Ifllfl ��1 �fl 1�� 1�� �� DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004033059 u, 1 U21 1 1 1 UI 1 U2 1 U, 1 1_12 1 U, 1 U2 1 1 10 u1 4 u2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El5501-51.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT) El AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00073157 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 m® ❑ RELATED PRIVATE ❑Y ®N 11 12 2025 ❑AM ❑YES ®NO U1 —< S MCLEAN BLVD Elgin mo /day/yr 03:54 ®PM FLOW CONDITION m l0 ®!MI ON E S W Bowes Rd COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 Cr) 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 0 18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑Peon. ❑Mies ❑NOV ❑ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C) FOR DAMAGEDAREA(S) FROM TOWED U1 Q Pernalete Perez.Johand s C. 1 0 / yr 13-UNDER CARRIAGE ©(O! 2 FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) EN O 2 DISTRACTED 0 0 U2 2 m F 2 SY 15-OTHER 4 ❑Y ®SNEM DUNK VEH. 0 AT CRASH 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 s, i�6 �i COM VEH 0 j$J 1 0 ELGIN I L 60120 0 1 0 FIRST CONTACT 11 7_: __5 *Ilves.See Sidebar U1 Z EQ86505 IL 2025 REAR TELEPHONE IL D 0 1 FM5K8F80GGB59772 Kemper ❑v ®N U2 Si , m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same 12RA000093570 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ® N 2 0 x DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 ivy 0 KCv 0 Dv 9 9 3 Mini Cooper 2016 00-NONE 0. Q!'-O DUE TO CRASH ❑ 2 x 0 y Yr 13-UNDER CARRIAGE 10( I 2 FIRE ❑ ® U2 C c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X ❑Y 10 N DUNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-it 6 11:,-4 COM VEH ❑ ® U1 W FIRST CONTACT 12 7�_,_.5 •(ryes.See SidebarC Z SOUTH ELGIN I L 60177 0 1 0 Q653641 I L 2025 I 0 M IL D 0 WMWXU3C52G2D29860 Geico ❑Y ®N RDEF71 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 = 99 9 Same 4534720455 BAc E 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 u 1 ® 11 1 11 ,12 /2025 03 54 ®pm in a Work Zone? ®N DIRP co 1 t PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 4 C) T 2 0 2 99 ! ! 0 PM• ❑Construction * o",R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM 0 Maintenance U2 a1 ® 11 1 ARREST NAME Pernalete Perez.Johandys.C. 11-901-A 1528-000319 / r El PM SLMT o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility AM t 2 0 ARREST NAME 1 / ❑❑PM 0 Unknown work zone type U1 3O 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 30 1528-Rivera. Kevin 701 269-Mendiola 12 ,22,2025 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••--, , I A CMV is defined as any motor vehicle used to transport passengers or property and: Z NI 1. Has a weight rating more than 10,000 pounds(example:truck or truck/trailer -< c ` --I -' I. INDICATE NORTH combination):or .Z-1 i BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C _ } (example:shuttle or charter bus):or 1 I t 1 3. Is designed to carry15 or fewer passengers and operated a contract carrier O L L.__-A-. } } } transporting employee in the course of their employment(example:employee transporter-usually a van type vehicle or passenger car): r ® CO L •-----}----+ 1�Bit�aean {�3I - } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver. C ®® for direct compensation(example:large van used for specific purpose):or O i. i t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires IJor2 placarding(example:placards will be displayed on the vehicle). XI I I Uni17#1 CARRIER NAME Z ADDRESS 0 I CITY/STATE/ZIP 0 g I - i. MOTOR CARR.ID 0 Interstate 0 Intrastate 5 1 I r 1 ❑ Not in Comm./Govt. Not in Comm./Other 0 ❑ 0 _-- _ Net To Scale - i. i. USDOT NO. ILCC NO. m XI Source of above z . 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 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 White Black 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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO. DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE