HomeMy WebLinkAbout2025-00073763 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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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 El$501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 202512025-00073763 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1
® ❑ RELATED ®Y 0 N 11 15 2025 ❑AM ❑YES ®NO U1
N LYLE AVE Elgin05:42
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W W H I G H LAN D AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD STOPPED U2 —I
Igl AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
/83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 Nuv 0!Cu 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 00 0
FOR DAMAGEDAREA(S) FRONT TOWED U1 0SORIANO.GERARDO 1 1 /
yr 13-UNDER CARRIAGE 10 1 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0U2 00 r 11<
M 2 SY 15-OTHER
4 ❑Y ®SNE❑UNK VEH. 0 AT CRASM IN H 0 99-UNKNOWN 916•TOP 3 `Distraction Value 9 ALGN 2
•
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S i�6 4 COM VEH 0 j$J 1 0
~ ELGIN I L 60124 0 1 FIRST CONTACT 12 7_; _5 *Irves.See Sidebar Ut
ZJ BABY-WS I L 2026 REAR
TELEPHONE
IL D JN1 BY1 PR2FM830589 BRISTOL WEST ❑Y ®N U2 13 . m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 RODRIGUEZ.JASMINE. N. G01-5250218-02 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 73
m g DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 NMv 0 NO! 0 Dv
!1 9 6 5 Honda CRV 2022 00-NONE till 12 :_y DUE TO CRASH rg ® U2 2 C
o yr mo 13-UNDER CARRIAGE III
c
F 2 6 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16•TOPO7 * X
❑YNi N DUNK VEH. AT CRASH 99-UNKNOWN O 0istracton Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-.;, 6 1.,( 4 COM VEH ❑ ® u1 CO
FIRST CONTACT 3 7-'_, _5 •(ryes.See SidebarC
I- ELGIN IL 60123 0 1 EX65179 IL 2025 I 0
IL D 3CZRU6H56NM761306 STATE FARM ❑Y ®N RDEF M
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
99 9 Same 3407162SFP13 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCTI (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 0 Y U2 Z
N 1 CD 11 4 11 r 15 l2025 05 42 ®pM in a Work Zone? NJ DIRP D
1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 3 n
O T
2 ❑ 2 99 / / 0 PM• El Construction
N 3 0 Ii CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
a SORIANO.GERARDO 11-901 1506-467 r ! PM
-, ARREST NAME ❑
o u 1 ® 11 4 �(CITATIONS ISSUED 0PENDING TIME • 0 Utility SLMT
o NSECTION CITATION NO. ROAD CLEARANCE 0 AM U1 30
r 2 El ARREST NAME SORIANO.GERARDO 6-303-A 1506-466 , r PM 0 Unknown work zone type
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1506-Nunez. Maria 602 12 , 81 r025 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.
.- .. , - A CMV is defined as any Bator vehicle used to transport passengers or property and: Z
r r 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
;.- -r- -; combination):or
INDICATE NORTH p1
Not To Scala I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- r r r (example:shuttle or charter bus):or
3. Is I- L____a____� g - I. I- . transportinggemploo aeeslin the course 5 or fewer o their employmentrs tl operatedxamp contract:employee carrier O
L �-----:----; W?CGHUWD7NYE j Ile— - •} } 1 transporter sed or d s gnated to transport between 9 and 15gpa passengers,including the driver. ((I)
for direct compensation(example:large van used fors specific purpose):or O
L L L L I L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
i
III
UNIT4 placarding(example:placards will be displayed on the vehicle). XI
i 1--._.,i- I CARRIER NAME Z
S ADDRESS 0
[IP
T.
CITY/STATE/ZIP
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- MOTOR CARR.ID 0 Interstate El Intrastate
r ❑ Not in Comm./Govt. Not in Comm./Other
�"-- ----1 - USDOT NO. ILCC NO. rn
XI
Source of above Z
. ❑ Yes 0 No 0 Unknown g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash?
❑ 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'; 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 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Gray Silver
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 2 TOWED BY/TO.
Arties/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 Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE