HomeMy WebLinkAbout2025-00078239 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X 4068 19'
u, 9 U29 2 1 1 U199 U2 U1 U1 99 U299 U,99 U2 99 5 15 u, 1 U2 1 *P 0119
INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ❑5501-51,500 ❑ON SCENE 1
VEHICLE/PROPERTY ®OVER 51,500 ®NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00078239 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 -n
N PORTER ST El In07:26
® ❑ RELATED ®Y 0 N 12 06 2025 ❑AM ❑YES ®NO U1
_ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION m
FT N E S W ADDISON ST COUNTY PROPERTY El ® N DOORING ❑y #OFMOTOR ❑SLOW 99 Cl)
❑ Kane HIT ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 —I
® &RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
FOR DAMAGEDAREA(S) FROPtf TOWED U1 0
Gonzalez.Omar 0 9 /
yr 13-UNDER CARRIAGE ta,l !�. 2 FIRE 0 (E <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 m
M 9 9 ❑Y ❑SNEM®UNK VEH. 9 AT CRASHD 9 99-UNKNOWN 9 16•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 1� 1 0
~ ELGIN N I L 60123 0 9 9 FIRST CONTACT 12 7 ; _5 *II Yes.See Sidebar U1
Z 4164406B IL 2026 REAR
TELEPHONE
UNK. D 1 FTEW1 EG4G KF49313 Progressive ❑Y ®N U2 m
5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
co
Lara.Vanessa,G. 861550403 2 m
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
r RESPONDER ( G0)
m N DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 MAV
yr Unknown Unknown 00-NONE 111 12 :_y FIRE DUE o CRASH ❑❑ U2 99 C
n 13-UNDER CARRIAGE ID Ti AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED 0 0 SPDR 0
SEX SAFT AIR 91,6•TOPO3 * 0
9 9 SYSTEM IN ENGAGED 15-OTHER
a ❑Y 0 N ❑UNK VEH. AT CRASH 99-UNKNOWN O Distraction Value 9
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-.;,• 6 1,..,_ COM VEH 0 0 U1 CO
FIRST CONTACT 3 7".'_, -5 *It Yes,See Sidebar
~ 0 9 UNKNOWN Unknown 1 C
9 ci)
M
UNK Unknown ❑Y 0 N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Lara.Vanessa,G. Unknown 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)
1 0
E/ MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 4 12,08 l2025 08 00 ®pm in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 0 23 18
N 3 0 0 CITATIONS ISSUED 0 PENDING + ! ❑PM• ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 3
-a, ARREST NAME ! ! El PM '
o N ® 11 `1 •
0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utilit 25
y
SLMT
r 2 0 ARRESTNAME AM
7 1 1 ❑❑PM 0 Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ ❑AM Workers present? ❑Y 25
565-Villagomez, Mireya 301 - 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.
r ----r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
` ` -' -' r INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} I - r r (example:shuttle or charter bus):or X
L 03. Is designed to carry15 or fewer passengers and operated a contract carrier O
}----------i J
- } } } transporting employee in the course of their employment� (example:employee � X
transporter-usually a van type vehicle or passenger car):or w
L L.__-a-_- 4. Is used ordesi natedtotrans transport passengers,including y} } } g po passen rs,includi the driver,
— _ _ w,ns - — — for direct compensation(example:large van used for specific purpose):or O
L L--_-a-___. i Trir P'" - i i 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). ;p
m.
CARRIER NAME —I
Z
- ADDRESS
T.
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Not To Scale I I CITY/STATE/ZIP 0
MOTOR CARR.ID 0 Interstate El Intrastate
. I . . ❑ Not in Comm./Govt. 0 Not in Comm./Other
r ------- '-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? 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
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Red Silver
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 1 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 9 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE