HomeMy WebLinkAbout2025-00078320 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 4 Sheets 01111101111
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 2025I 2025-00078320 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 16 �I
® ❑ RELATED ®Y 0 N 12 09 2025 ®AM ❑YES N NO U1
S MELROSE AVE Elgin06:43
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION ITl
FT!MI N E S W CARR ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 u)
❑ Cook HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ® FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PeoA,. 0 EWES 0 RIAv 0 ucv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FROt'rr TOWED U1 Q
NAME(LAST,FIRST,M) GONZALEZ.GUSTAVO mo Ford Custom 2019 00-NONE ,1 . O i•, ODE TO CRASH ❑
EN
13-UNDER CARRIAGE 10 ' 2 FIRE ❑ IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0U2 2 171
M 2 4 ❑Y SYSTEM IN ENGAGED OTHER 9 16.TOP 3 _
El N DUNK VEH. AT CRASH 9 -UNKNOWN `Distraction Value 9 ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s ;i�B �i 4 COM VEH 0 ix) 1 0
F. FIRST CONTACT 2 7 :—_t-_5 *IIYes.See Sidebar U1
Z GILBERTS IL 60136 0 1 212553TW IL 2026 REAR
TELEPHONE
IL D 1 FDUF4GY1 KEG81743 Pioneer Specialty ❑Y J N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 40312 3 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ❑ N 13 0
p; DRIVER ❑ PARKED 0 DRIVERLESS ❑ FED ❑PEDAL 0 EWES O iiuv 0 KCv ❑Dv
!1 9 8 5 Honda Pilot 2020' 00-NONE 11"j t2 , DUETO CRASH ❑ 2
0 13-UNDER CARRIAGE FIRE ❑ N U2
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F 2 4 SYSTEM IN ENGAGED 15-OTHER 9 16•TOPO3 * 9 0 X
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN O Detraction Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s-.il-.- 4 COM VEH ❑ N U1 CO
FIRST CONTACT 2 Y -`-�•bYes,See Sidebar
ELGIN IL 60120 0 1 EH55190 IL 2026
IL D SFNYF6HSOLB069488 Erie Insurance ❑y N N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same Q040813356 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND
0 N ui =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT( (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
2 6 04 /
LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ElY U2 Z
N 1 ® 43 1 City. Elgin Stop Sign on Carr St EIB 12,09 /2025 06 43 ®❑PM in a Work Zone? ®N DIRP co
1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1
2 0 150 DEXTER CT ELGIN IL 60120 23 99 12,09 ,2025 06 43 PM
1
❑ • 0 Construction >F
Z J 3 0 ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
®AM ❑Maintenance U2
a ARREST NAME 12/09/2025 06 45 ❑pM
1 ® 11 1 0 CITATIONS ISSUED PENDING utility SLMT
NSECTION CITATION NO. ROAD CLEARANCE TIME
o 0 y
AM U1 30
r 2 0 ARREST NAME 12(09 12025 06 43 in PM 0 Unknown work zone type
T
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 - ❑AM Workers present? ❑Y 30
387-Root. Mark sot , ❑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
J IH 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
O combination):or —I
r , r INDICATE NORTH 1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
_ } (example:shuttle or charter bus):or
C)
5
r
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< <---- -• •; c.rra • transporting mployeeslin the courses o heu maployment example:employeener X
} } }
f� transporter-usually a van type vehicle or passenger car):or
L L-----}----. >i 1 - 1 I- . 4. Is used or designated to transport between 9 and 15
assen including the driver. C
t l_ - for direct compensation(example:large van used fors specific purpose):or
L L____a____.: _ _ _ 1_ _ _ _ I. i I i L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
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placarding(example:placards will be displayed on the vehicle). XI
—1
CARRIER NAME Z
—01 V.i ri
V _ ADDRESS 0
D
cCITY/STATE/ZIPOg
MOTOR CARR.ID 0 Interstate ❑ Intrastate
Not To Scale 0
I r ❑ Not in Comm./Govt. Not in Comm./Other
❑ 0
--- - 1 - USDOT NO. ILCC NO. m
XI
Source of above z
. MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No 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
White Gray
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 DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE