HomeMy WebLinkAbout2025-00077775 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 6 Sheets 0111110111111 01110
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X0040683.09`
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑5501-51.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 202512025-00077775 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 �I
222 DUNDEE AVE El In04:03
® ❑ RELATED ❑Y ®N 12 06 2025 ®AM ❑YES ®NO U1 —<
_ g PRIVATE mo /day/yr ID PM FLOW CONDITION m
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COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW fA
❑ FT/MI N E S W Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ® FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEON. 0 EWES 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0
1 2 /
yr 13-UNDER CARRIAGE 10 I 2 FIRE ❑ ® C
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 rn
M 2 4 SYTM❑Y ®SNE❑UNK VEH. 0 AT CRASH 99-UUNKNOWN THER9 t6•T DP 3 *Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF iL 6 I,.4 COM VEH 0 LK 1 0
~ ELGIN I L 60120 0 1 0 FIRST CONTACT 12 7_: __5 *lI Yes.See Sidebar U1
Z 4244360B IL 2025 REAR
TELEPHONE
IL D 1D7HU18DX4S593970 Unknown ❑Y ❑N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
99 9 Gonzalez. Marco.A. Unknown 4 r
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 ou
0 DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 N,IV 0 Ncv 0 DV
yr 12 _ 71
Ti 13-UNDER CARRIAGE 10 I c., 2 FIRE ❑ ❑ U2 C
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 9.1,6.TOP 3 0 0 SPDR 0
0 Y ❑N 0 UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value U1 9 -
POINT OF s .;, 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRSTO CONTACT Y 6 L'k:_6 CIOMs gee Sidebar
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M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O
❑Y ❑N RDEF73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
BAC
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
RESPNDER❑YO❑N U1 =
(UNIT) (SEAT) (DOB1 (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 0
1 3 09 / M 9 4 0 1 0
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/ / #OCCS >
/ / UI 2 D
/ / 0
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 43 3 12,06 /2025 05 40 ®❑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 ❑ 20 19
! 1 0 PM• 0 Construction *
t
Z3 ❑ xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2
—a, ARREST NAME Miranda.Juan.A. / / El PM 11 502.15 748032
o u 1 ❑ �!CITATIONS ISSUED ❑PENDING UtilitySLMT '
SECTION CITATION NO. ROAD CLEARANCE TIME AM 0•
t 2 El ARREST NAME Miranda.Juan.A. 11-708 748033 12106 /2025 04 45 M PM 0 Unknown work zone type U1 30
n 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y
1505-Caliendo.Anthony tot 331-Ziegler 01 1 09,2025 09 00 ❑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.
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A CMV is defined as any motor vehicle used to transport passengers or property and: Z
�____r____; // _ combination):. Hasweight rating more than10,000pounds(example:truckortruck/trailer 1 -<
// INDICATE NORTH 73
/ / BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i_ �t..r.hNO / - } (example:shuttle or charter bus):or 0
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4ge
/ ��-- 3. Is desgned to carry15 or fewer passengers and operated a contract carrier O
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I. } } transporting employee in the course of their employment(example:employee 73
/ �--' 1 transporter-usuallya van vehicle or/ / po type passenger car):o 03
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-----" ® nor>b e�e..rl 1. } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver. C
for direct compensation(example:large van used for specific purpose):or O
L __i_. .: - I ._ 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
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/ / placarding(example:placards will be displayed on the vehicle). ;p
O O IOx.
/ CARRIER NAME Z
/ / - ADDRESS 'n
/ / D
// / CITY/STATE/ZIP g
/ / <
/ - MOTOR CARR.ID 0 Interstate ❑ Intrastate
1 1 r ❑ Not in Comm./Govt. Not in Comm./Other
❑...-
0
; _Y____1 USDOT NO. ILCC NO. m
XI
Source of above z
GVWR/GCWR —I
0 <10,00o 0 10,000-26,000 0 >26,000 z
Were HAZMAT placards on vehicle? 0 Yes 0 No =
If Yes,Name on placard O
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
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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_COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Gray
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U_DUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO:
DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE