HomeMy WebLinkAbout2025-00078554 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111 III 11 IIIIII UHI U
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT El No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00078554 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1
200 N WESTON AVE EIIn09:00
® ❑ RELATED ❑Y ®N 12 10 2025 ®AM ❑YES ®NO U1 -<
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 15 cn
❑ FT/MI NESW Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS O
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV ❑CM DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
0 2 /
yr 13-UNDER CARRIAGE 10 1 2 FIRE 0
NI
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
M 2 SY is-OTHER
4 ❑Y ®SNE❑UNK VEH. 0 AT CRASH M IN D 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF & i�s �i COM VEH 0 j$J 1 0
~ ELGIN I L 60123 0 1 0 FIRST CONTACT 2 7_: __5 *Yves.See Sidebar Ut
Z EW81014 IL 2026 REAR
TELEPHONE
IL D WBA3B3C58DF539434 Allstate ❑v ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR
ce
Elgin Fire 99 9 GUTIERREZ,JOEL 975781930 4 m
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER >
Refused ❑Y ® N 2 XI
x DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑NMV 0 NOV ❑DV
/1 9 9 4 FROM TOWED
Suburban 2017 00-NONE 1("j 12..-_1 DUE TO CRASH ❑ ! l 2 x
0Yr 13-UNDER CARRIAGE 10'( 2 FIRE El U2 C
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F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 g
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 1 S l:; COM VEH 0 im ut W
F,,, FIRST CONTACT 4 O7 ,�=_Q�._5 •)(Yes.See SidebarC
ELGIN Z IL 60123 0 1 0 BG41723 IL 2026 AR 0
M
IL D 1 G NSKJ KC2H R310147 Progressive ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire 1 99 Same 940228930 BAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 12/10 /2025 09 00 ®❑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 C)
2 0 11 15 12/10 /2025 09 01 PM
❑ ❑Construction *
Z 3 0 O CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
®AM ❑Maintenance U2
- N a ARREST NAME 12,10/2025 09 05 ❑pM '
,
1 ® ❑Utility
1 1 1 0 CITATIONS ISSUED SECTION CITATION NO. ROAD CLEARANCE TIME PENDING SLMT
o
AM 20
r 2 0 ARREST NAME 12/10 /2025 10 14 MPM ElUnknown work zone type u1
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ - ID Workers present? ❑Y 20
1553 Jentsch.Clarissa 607 / / 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
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 -<
i- }---.r----; INDICATE NORTH combination):or
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BYARROW 2 Isusedordesi nedtotrap ortmorethan15 co
N) - } . (example:shuttle or charter bins):or passengers including the driver
4E
3. Is designed tocarry 15 or fewer passengers and operated a contract carrier
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Not[10— To Scala } } } transporting employees in the course of their employment(example:employee73
transporter-usually a van type vehicle or passenger car):or 0
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4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver,
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L___-a-...1 —um1 —41't2—
MOMS _ L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example:placards will be displayed on the vehicle). m;p
1 r I' I' I' I-- --I-
CARRIER NAME :-.1
ADDRESS
I
ICITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other
;____Y___ 4. - USDOT NO. ILCC NO. rn
XI
Source of above z
. ❑ Yes J No ❑ Unknown A
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 VIM 1 m
to
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Blue Black
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE