HomeMy WebLinkAbout2025-00080283 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X0O4O760
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INVESTIGATING AGENCY DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ❑OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
El AMENDED ElB Injury and for Tow Due To Crash YR 2025I 2025-00080283 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
® ❑ RELATED ®Y 0 N 12 19 2025 ❑AM ❑YES ®NO U1 -<
NATIONAL ST Elgin04:59
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION Ill
FT!MI N E S W RAYMOND ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15
❑ Cook HIT&RUN ®Y ❑ N WITH VEHICLESOT,
INVLD DO
U2 —I
El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
/1 9 8 8 BMW 330 2003 00-NONE 11 FROM
• O I_1 DUE TO CRASH ❑ ® E
13-UNDER CARRIAGE 1a i : 2 FIRE 0IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED El U2 2 m
M 2 SYTM IN ENGAGE15-OTHER
4 ❑Y ®SNE El UNK VEH. 0 AT CRASHD 0 99-UNKNOWN 9 76•TOP 3 *Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _iL a 4 COM VEH 0 j$J 1 0
F. FIRST CONTACT 12 7_;—, _5 *Yves.See Sidebar U1
Z Wood Dale IL 60191 0 1 0 541AC549 IL 2026 REAR
TELEPHONE
IL D 0 WBAEV53443KM24466 None ❑Y 0 N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same None 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER en
Refused ❑Y El 2 0
p; DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED 0 PEDAL ❑EWES 0 row 0 KCV 0 Dv
1 9 9 3 Chevrolet Suburban 2003 00-NONE ,._j 12--_, DUE TO CRASH ❑ 2 x
o Yr 13-UNDERCARRIAGE 101; 2 FIRE ❑ ® U2 C
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istracllon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 5 I S .!,_4 COM VEH ❑ ® Ut CO
FIRST CONTACT 6 7 -�-_5 •((Yes.See Sidebar C
ELGIN IL 60120 0 1 0 CJ51594 IL 2026 FIRST Si)0
M
IL D 6 3G N FK16Z03G 111994 United Equitable Insuranc ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Ruiz. Lisette ILU017001 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)
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EV MOST EVNT LOC. DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 1 12,19 /2025 04 59 ®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
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2 28 19 1 1 0 PM ❑Construction *
Z 3 ❑ DygCITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
o ® 11 1 ARREST NAME Gomez.Carlos 11-601-Ax 482000621 / / El PM SLMT
•
I$!CITATIONS ISSUED ❑PENDING SECTION CITATION NON . ROAD CLEARANCE TIME AM• El Utility
o t 2 El ARREST NAME Gomez.Carlos 3-707 482000622 121 19 12025 04 59 ®PM El Unknown work zone type U1 30
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 30
482-Flentye,Jeremy 401 01 1 06 12025 01 30 ®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
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combination):. Hasr thanpound (example:truck or truck trailer 1. Hasaweightrating more10,000 5 -I
INDICATE NORTH o p3
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
o
i_ - (example:shuttle or charter bus):or X
L L.___A.._.' i{ 3. Isdesgnedto carry 15or fewer passengers and operated bya 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 w
L L.___a.._..l "otioninst 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including N
- - - - - - - } } } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or �
t i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D
u�_ placarding(example:placards will be displayed on the vehicle). XI
e 2).1 CARRIER NAME
ADDRESS 0
T.
` - CITY/STATE/ZIPNot To Scale
MOTOR CARR.ID ❑ Interstate ❑ Intrastate
unit ❑ Not in Comm./Govt. ❑ Not in Comm./Other 00
‘I. - --1 - USDOT NO. ILCC NO. C
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XI
Source of above z
.
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
Black White
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: 0 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE