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HomeMy WebLinkAbout2025-00074349 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Df 2 Sheets 01111101111 IIIIII II 1111 III IIIIIIIIIIIIIIIIIII DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X0040140715 u, 1 U21 1 1 2 U1 2 U2 1 U1 1 U2 1 U1 1 U2 1 4 10 U, 3 U2 3 .P0119* INVESTIGATING AGENCY DAMAGE TO ANY El 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$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash El AMENDED YR 2025I 2025-00074349 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME S LIBERTY ST Elgin06:18 SECONDARY CRASH 2 ® ❑ RELATED ®Y 0 N 11 18 2025 ❑AM ❑YES ®NO U1 -< _ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION m FT!MI N E S W LAUREL ST COUNTY PROPERTY ❑Y ® N DOORING ICIy #OF MOTOR El SLOW 1 cn ❑ Cook HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 /83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 UUV 0!CV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 n FRObir TOWED U1 Q NAME(LAST,FIRST,M) Arenas Gonzalez. Benito mo yr Chevrolet Silverado 2018 00-NONE , OUE TO CRASH ElEN 13-UNDER CARRIAGE a 0 12 l I _! 2 FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 0 U2 0 m M I 2 4 ❑Y ®SNEM❑UNK VEH. O AT CRASH IN ENGAGEDO 99-UNKNOWN 9 16•TOP 3 *Detraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, i�B �i 4 COM VEH 0 j$J 1 0 ~ 60110 0 1 0 FIRST CONTACT 11 7_: __5 *rives.SeeSidebar U1 Z DL4809 IL 2026 REAR 7 TELEPHONE IL D 0 1 GC1 KVEG 1 J F156029 Elite Insurance El Igl N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Kennedy Motors 006471563 2 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 m x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 Nu,ty 0 txv 0 Dv CIRCLE NUMBER(S) U1 /1 9 9 2 Honda CRV 2014 oo-NONE „ ._.©i-_, DUE TO CRASH rg ❑ 2 x 0 13-UNDER CARRIAGE FIRE 0 ® U2 C c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER O9 16-70P 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S I S i',.4 COM VEH 0 ® Ut CO FIRST CONTACT 11 7 __5 •If Yes.See Sidebar C ELGIN IL 60120 0 1 0 EA19439 IL 2026 REAR— Si)0 IL D 0 5J6RM4H52EL013139 Statefarm ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X Medrano.Teresa 1050285SFP13 BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) U2 996 r m ##occs y / ,, U1 1 Ill 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 4 11 ,18 l2025 06 18 ®PM in a Work Zone? ®N DIRP co 1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 5 C) T 1 2 0 2 99 / ! ❑PM ❑Construction X Z 3 0 ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 -a, ARREST NAME / / ❑PM ' 1 ® 11 4 0 CITATIONS ISSUED ❑PENDING UtilitySLMT o N SECTION CITATION NO. ROAD CLEARANCE TIME ❑ r 2 0 ARREST NAME 1 l r 18 12025 07 03 ®PM 0 Unknown work zone type El AM U1 35 n T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 El ❑AM Workers present? ❑Y 35 1500-Chew. Marie 302 391-Jacobucci , ❑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 • C4D ADDITIONAL UNITS FORMS. I - ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -< i- }__-_r_-__1 I } combination):or INDICATE NORTH p0 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C (example:shuttle or charter bus):or C I i w ' Not To Scale 1 3. Is desgned to carry 15 or fewer passengers and operated by a contract carrier I O ii } } } transporting employees In the course of their employment(example:employee J � transporter-usually a van type vehicle or passenger car):or CO L }-----}----; - } } } •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____. t i i _ 5. Is anyvehicle used to transport anyhazardous material(HAZMAT)that requires i i placarding(example:placards will be displayed on the vehicle). m La St I Untt2 CARRIER NAME ADDRESS 0 IT. CITY/STATE/ZIP C MOTOR CARR.ID 0 Interstate 0 Intrastate I I T I I ❑ Not in Comm./Govt. ❑ Not in Comm./Other 0 --- --1 i - USDOT NO. ILCC NO. m Source of above z . xi 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 M 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 0 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Yellow White 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 DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE