HomeMy WebLinkAbout2025-00070192 ILLINOIS TRAFFIC CRASH REPORT sheet 1 or 4 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X0D4048234
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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 2
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 B Injury and/or Tow Due To Crash
El AMENDED
YR 202512025-00070192 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 —n
JEWETT ST Elgin
® ❑ RELATED ❑Y ®N 10 27 2025 ❑AM ❑YES ®NO U1 -<
PRIVATE mo /day/yr 06:15 ®PM FLOW CONDITION m
®10 ®!MI 0 E S W North Locust St COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 1 (n
Kane HIT&RUN ❑V ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 —I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
183 DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 NW 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 02 n
FOR DAMAGEDAREA(S) FRONT TOWED U1 Q
Lara Gamboa. Francisco.J. 0 3
yr Q -
13-UNDER CARRIAGE 1a 2 FIRE ❑ al STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ]$I U2 02 m
M 2 SYTM IN ENGAGE15-OTHER
4 ❑Y ®SNE DUNK VEH. O AT CRASHD O 99-UNKNOWN 9 76•TOP 3 *Distraction Value I ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ ;iI a 4 COM VEH 0 1� 1 0
~ ELGIN I L 60123 0 1 0 FIRST CONTACT 12 7 ;1 _5 *Yves.See Sidebar U1
Z FA50474 IL 2025 E
TELEPHONE
IL D 0 1 G4GE5ED3BF362926 American Free Insurance ❑Y ISI N U2 m
.5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 12-2476495-00 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 0
0 DRIVER I} PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 Nuy 0 NOV 0 Dv CIRCLE NUMBER(S) U1
yr 11_.I 12 -1 ❑ ® 1 C
.. 13-UNDER CARRIAGE 10 I 2 FIRE ❑ ® U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL)
9 16.TOP 3 DISTRACTED 0 ® SPDR n
0 0 SYSTEM IN ENGAGED 15-OTHER 1 0
a ❑Y NJ ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value
POINT OF 8 ) "4 U1
H CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR O �!._ COM VEH ❑ ® CO
FIRST CONTACT 7 7 _, _5 •If Yes.See Sidebar
3957381B IL 2026 REAR
0 Si)
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
1 FTEW1 E55LFC04602 Kemper Insurance 0 Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
Jasso Rivas.Alfredo 12A0001559963 BAC
$
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)
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 18 1 10/27 /2025 06 15 ®AM in a Work Zone? ®N DIRP co
I I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
57 2 0 18 1 15 28 10,27 /2025 06 25 PM
,
® • ❑Construction >F
R O ❑ CITATIONS ISSUED El PENDING SECTION CITATION NO. EMSARRIVEO TIME 7
3 ❑AM ❑Maintenance U2
oEl 11 1 ARREST NAME Lara-Gamboa. Francisco.J. 11-601 1511000396 10/27/2025 06 28 ®PM SLMT
o N ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
D AM
r 2 ❑ ARREST NAME 10/27 /2025 06 20 0 PM El Unknown work zone type U1 25
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? 0 Y 25
1511-Ayala. Roberto 700 11 , 18/2025 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••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
U1M2 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
` ` --I -' r INDICATE NORTH combination):or .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ } (example:shuttle or charter bus):or
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I- ------I----; transportingtlgem lloyeeo slin the course of5 or fewer passengersnanodyment example:employee a contract der
} } } p employment
a0 transporter-usually a van type vehicle or passenger car):or
L L.___a__ 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or
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L L----A----; unk Not To Scale - } t 5. Is any vehicle used to transport hazardous material(HAZMAT)that requires m
i Aany
placarding(example:placards will be displayed on the vehicle).
CARRIER NAME Z
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ADDRESS 'n
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C)
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
❑ Not in Comm./Govt. ❑ Not in Comm./Other
0
lontPet
;_... . ._.; USDOT NO. ILCC NO. m
XI
Source of above z
. If Yes,Name on placard 0
4 digit UN NO. 1 digit Hazard class No. Xl
Xl
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 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 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
Tan Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Artier/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE