HomeMy WebLinkAbout2025-00079566 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
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INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ® q 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 51,500 ❑NOT ON SCENE(DESK REPORT)
El AMENDED ElB Injury and f or Tow Due To Crash YR 2025I 2O25-00079566 VENT
ADDRESS NO. HIGHWAY or STREET NAME ® ❑CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
RT20 RELATED t3I Y 0 N 12 15 2025 04:40 12,— ❑YES ®No u1 -<
Elgin PRIVATE mo /day/yr ®PM FLOW CONDITION rf1
FT N E S W NESLER RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR El SLOW 1 cn
❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD ® STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 NOV 0 Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) y N 2 1 1 0
FOR DAMAGEDAREA(S) FROM T TOWED U1 O
NAME(LAST,FIRST,M) MANUELES ROMERO. RENE.A. mo /
13-UNDER CARRIAGE 10 i , 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL)THERDISTRACTED 0 0 U2 2 rr1
M 2 4 SYTM❑Y ®SNE❑UNK VEH. 0 ATCRASHD 0 15-99-UUNKNOWN 9 76•TOP 3 `Distraction Value ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 7_iL 6 I,.4 COM VEH 0 E! 1 0
~ DES PLAINES ES I L 60016 0 1 0 FIRST CONTACT 12 7_: _5 *lives.See Sidebar U1
ZFR34272 IL 2026 REAR
TELEPHONE
IL D 0 JHLRD1863YC035607 Falcon Insurance Co. ❑Y Il N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 0100140742 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 eu
g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uv 0 NOV 0 Dv
1 9 yr 6 Unknown Unknown 2024 00-NONE ,i_"j Qi-_, DUE TO CRASH ❑ 2
0 13-UNDER CARRIAGE 1a) I. E FIRE ❑ ® U2 C
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraelion Value 0
POINT OF s iI 4 COM VEH ❑ ® Ut CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR - MI'
FIRST CONTACT 6 Y__{_ s•_5 •If Yes.See Sidebar
Z GILBERTS IL 60136 0 1 0 EY78541 IL 2026 i 0
Z
IL D 0 Liberty Mutual ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER I =
99 9 Same A0V2437816674047 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER
u1 =
{UNIT) (SEAT) IDOBI (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
2 3 08 /
2 O
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 12,15 r2025 04 40 ®pm in a Work Zone? NJ N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
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2 28 18 ( ( 0 PM• ❑Construction *
R 3 0 $I CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM 0 Maintenance U2
-a, ARREST NAME MANUELES ROMERO. RENE.A. 11-601 1560000219 , r ❑PM SLMT '
o U 1 ® 11 1 ❑ Utility
o N SECTION CITATION NO. ROAD CLEARANCE TIME AM• Ely
CITATIONS ISSUED PENDING
T 2 0 11 1 ARREST NAME 12 r 15 r2025 04 40 ®PM 0 Unknown work zone type U1 50
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 50
1560-Jones. Bennett 801 269-Mendiola 01 ,01 ,2026 09 00 p 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 truckrtrailer -<
c ` --I -' r INDICATE NORTH combination):or .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ } (example:shuttle or charter bus):or
X
L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
} } } transporting employees In the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or CO
' "'�` '"�"""' • 1 I- I- 4. Is used or designated to transport between 9 and 15 passengers,including the driver, N
_ for direct compensation(example:large van used for specific purpose):or O
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. I I 1 t 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
Nat To Score t - • • • • __ D
^ +^� N CARRIER NAME —I
Z
ADDRESS 0
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CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other
-"-----"1 - USDOT NO. ILCC NO. m
XI
Source of above z
. 0 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 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
Gray
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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE