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HomeMy WebLinkAbout2025-00077953 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Df 2 Sheets 01111101111 10110 ll 1111 10011 00 0011 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X 066548 u, 1 U21 1 1 3 U, 4 U216 U, 1 1_12 1 U, 1 U2 1 1 11 U1 14 U214 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 11 VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00077953 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 71 ® ❑ RELATED ❑Y ®N 12 07 2025 ®AM El YES El NO U1 159 E ROUTE 20 Elgin PRIVATE mo /day/yr 09:51 ❑PM FLOW CONDITION III ®17T)!MI N 0 S W South Mclean Blvd COUNTY PROPERTY ❑Y ® N DOORING ❑Y #OF MOTOR ElSLOW 15 u) Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ® STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZ1 N ❑ FREE FLOW # LNS 0 18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 Nuv 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 02 n FOR DAMAGEDAREA(S) FRONT TOWED U1 Q Cruz-Gomez. Miguel.A. 1 0 / yr 13-UNDER CARRIAGE ©i FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O 2 DISTRACTED 0 0 U2 02 m M 2 4 El ®SNE❑UNK VEH. 0 AT CRASH IN ENGAGED0 99-UUNKNOWN 016 3 `Distraction Value 9 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 iI 6 4 COM VEH ❑ j$J 2 O ~ Hanover Park IL 60133 0 1 0 FIRST CONTACT 10 7 ; __5 *If Yes.See Sidebar U1 Z BE71317 IL 2026 E TELEPHONE IL D 0 7FARW2H50KE001529 State Farm ❑Y igi N U2 19 . m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR co 99 9 Same 2037599-SFP-13 3 m `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER XI Refused ❑Y ❑ N 2 0 x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMV 0 KCV 0 Dv � 1 9 yf 7 Jeep(after 1911 ngler 2020' 00-NONE 11_"j t2--_, DUETO CRASH ❑ 2 x o 13-UNDERCARRIAGE ta;l 2 FIRE ❑ ® U2 C Ti F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN O *0istraellon Value 9 g POINT OF 8 II 4 COM VEH D ® Ut CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR .I 6 ,. FIRST CONTACT 5 7-- OS *IfYes.SeeSidebar C Elgin IL 60123 0 1 0 CE22472 IL 2026 aR g fp IL D 0 1C4HJXEN4LW152376 State Farm ❑Y J N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Valdez.Gelasio 3486496-SFP-13 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 D 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 1 12,07 r2025 09 51 ®❑PM AM in a Work Zone? ®N DIRP D co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 � o" 2 ❑ 28 11 ) ) ❑PM. ❑Construction * 1 • R 3 ❑ $I CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM ❑Maintenance U2 a1 ® 11 1 ARREST NAME Cruz-Gomez. Miguel.A. 11-601 W1543000289 r r El PM SLMT o N • ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility 35 t 2 ❑ ARREST NAME AM T 1 r ❑❑PM ❑Unknown work zone type U1 n OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 D ❑AM Workers present? ❑Y 35 1543-Sturgeon. Kyle 700 - r { ❑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 asmotor vehicle used to transportand: r ----,5-••--, ; any passengers or property Z 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -< • i.-- -i-- --; } } } r -, , ; ; , ; ( INDICATE NORTH combination):or —I p1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } ' i 1 , } (example:shuttle or charter bus):or X 3. Is L L.___A_. 1 i. <-- . -___� J transporting employened to es Inhecourse 5 or fewer o their eers mplod yment example:employeener X } } } transporter-usually a van type vehicle or passenger car):or 1:0 < <.__-a-_-_, , < <--_-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 0 L L___-a____.: L L L ...._-.�____� l. i i ._ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example:placards will be displayed on the vehicle). XI --I CARRIER NAME Z ADDRESS 0 CITY/STATE/ZIP MOTOR CARR.ID 0 Interstate ❑ Intrastate 0 ❑ Not in Comm./Govt. ❑ Not in Comm./Other O 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 0 No 0 Unknown T. 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' T TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Gray Yellow 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: 2 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE