HomeMy WebLinkAbout2025-00075065 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets _ III III H IIII mil U �l II ill 1HuH
1�� 11111
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004040659
u, 9 U2 1 1 9 u, 2 U2 U,99 1_12 U,99 U2 1 9 9 U1 1 U221 *P 0119*
INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY 0 5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00075065 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 71
862 S LIBERTY ST Elgin06:49
® ❑ RELATED ®Y 0 N 11 22 2025 ®AM ID YES El NO U1 —<
_ g PRIVATE mo /day/yr ❑PM FLOW CONDITION MCOUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ FT/MI NESW Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER O PARKED O DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 1 0
/ ! FOR DAMAGEDAREA(S) FROPtf TOWED U1
Unknown.O. Unknown Unknown 00-NONE it.. 12 i OUETOCRASH ❑ EN
NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE IE
10 ! 2 FIRE El
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 1 r<11
SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3
9 9 ❑Y El N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN =
$ 4 COM VEH 0 Ea r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _,I[B !I,_ 1 0
I— 0 9 FIRST CONTACT 99 7_; _5 *II Yes.See&debar U1
REAR
2 Z ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 2 111
Unknown ❑Y ❑N U2 I—
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same Unknown 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ❑ N 99 0
mo DRIVER X. PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 Nuv 0 K V 0 DV
yr ��1 t2 c, 2 FIRE ❑ ElU2 2 C
o _ 13-UNDER CARRIAGE ;
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP3 ❑ ® SPDR n
❑Y ®N DUNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 0 -
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 0,: �.. 4 COM VEH ❑ ® U1 CO
F,,, FIRST CONTACT 7 O7 � =_laQl�.S •(ryes,See Sidebar
EW14050 IL 2025 aR 0
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
1 HGCR2F55DA035300 Progressive ❑V ®N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Morales. Rodrigo 999876390 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
U2 996 r
m
##occs >
71
/ / U1 1 D
/ / 0
EV MOST EVNT DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 18 9 11 ,22 /2025 06 49 ®❑PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 ❑ 18 99
N 3 ❑ 0 CITATIONS ISSUED 0 PENDING + ! ❑PM, ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5
z
—a, ARREST NAME / / El PM '
1 ® 1 1 1 ❑CITATIONS ISSUED PENDING UtilitySLMT
N SECTION CITATION NO. ROAD CLEARANCE TIME
o ❑
AM u, 15
r 2 El ARREST NAME 1 1)22 12025 07 32 0 PM 0 Unknown work zone type
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ — El Am Workers present? ❑Y 15
1540-Allah. Muhammad 401 , , 0 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
S?LlbertYtSt ADDITIONAL UNITS FORMS.
r ----r••--, , I ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
r J I combination):or g ore than pound { a p .truck or truckrtrarler 01. Hasaweight ratio m 10000 5 ex m le -<
t31u1RCIty7Blvd INDICATE NORTH p3
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
— — _ — — — — — - } (example:shuttle or charter bus):or
X
A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
,o /i - I. } } transporting employees in the course of their employment(example:employee 73
transporter-usually a van type vehicle or passenger car):or C
4. Is used ordesi natedtotrans rtbetween9and15 passengers,includingN
} } I. for direct compensation(example:large van used for cific purpose): the driver,
Pe ( P 9 Pe P Pose):or O
i - L i i t 5. Is anyvehdeusedtotransportanyhazardousmaterial(HAZMAT)thatrequires m
ro placarding(example:placards will be displayed on the vehicle).
XI
, D
I CARRIER NAME Z
i N z
I ADDRESS O
I Not To Scele ' T.
rn
CITY/STATE/ZIP n
MOTOR CARR.ID 0 Interstate El Intrastate
Dixon?Ave- - O
I I T I ❑ Not in Comm./Govt. ❑ Not in Comm./Other
0
1 I USDOT NO. ILCC NO. m
XI
Source of above z
. • m
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 ❑ No ❑ Unknown g
D
Did Carrier Safety Regulations(MCS)violation contribute to the crash?
El Yes Yes I No 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 ❑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
to
LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 0 0 0 Z
1-1
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Silver
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT g TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE