HomeMy WebLinkAbout2025-00080487 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X0D4076036
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑$501-51.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
0 AMENDED YR 202512025-00080487 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 m® ❑ RELATED PRIVATE ❑Y ®N 12 20 2025 ❑AM ❑YES ®NO U1 -<
S JANE DR Elgin mo /day/yr 11.52 ®PM FLOW CONDITION m
2310q0!MI N E O W Gordon Ct COUNTY PROPERTY ElY 21 N DOORING ICI #OF MOTOR 0 SLOW 2 fA
Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
(g)DRIVER I] PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 uuv 0 ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
1 2 FOR DAMAGEDAREA(S) FRO A TOWED U1 O
NAME(LAST,FIRST,M) Gomez-Cardona. Franklyn. R. mo Ford Expedition 2003 00-NONE
DUE TO CRASH ® ❑
e/ / yr p Q_ 12
13-UNDER CARRIAGE 9 I I! 2- FIRE ❑ al
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 0 U2 2 m
M 2 SY 15-OTHER
4 ❑Y ONM DUNK VEH. O AT CRASH IN D O 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, i�a �i COM VEH 0 Ea 4 0
ELGIN I L 60123 0 1 0 FIRST CONTACT 11 7_: __-5 *Ilyes.See Sidebar U1
ZFW36419 I L 2026 REAR
TELEPHONE
IL D 0 5LMFU28R33LJ49706 American Freedom ❑Y ISIIL' N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
co
99 9 Same 12250317500 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER en
Refused ❑Y ® N 2 0
0 DRIVER X. PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 NMV 0 KCV 0 DV
yr Ford F150 2020 00-NONE al t2 "_, DUE TO CRASH p ® 1 ,'a
0 13-UNDER CARRIAGE 9 l 2 FIRE 0 ® U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 ® SPDR 0
SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 9
a D Y El ❑UNK VEH. AT CRASH 99-UNKNOWN *0istraellon Value
POINT OF 8it 4 Ut
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR ��'`_ COM VEH ❑ ® CO
FIRST CONTACT 11 7 _,__5 •If Yes.See Sidebar
~ 3512390B IL 2026 I 0 Si)
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
0 1 FTFW1 RG9LFA91558 none ❑Y ®N RDEF73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
99 9 Camarena.Jaqueline none SAC E
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)
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 18 1 12,20 ,2025 11 52 ®AM 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
Fsi 2 ❑ 20 19
N 1 3 ❑ CITATIONS ISSUED 0 PENDING / 1 ❑PM• El Construction >F
SECTION CITATION NO. EMS ARRIVED TIME 8
❑AM ❑Maintenance U2
z
-a, ARREST NAME / / ID PM '
S' N ® 11 1 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT
30
t 2 ARREST NAME AM
7 ! r ❑❑PM ❑Unknown work zone type U1
% El
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1560-Jones. Bennett 602 331-Ziegler 01 ,23,2026 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.
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- }___--I-----; a.'+J•n•'+a. \ \ _ combination):or
INDICATE NORTH p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
r (example:shuttle or charter bus):or 0
3. Is designed to carry15 or fewer passengers and operated a contract carrier O
I- <---------•i ` }} } transporting employee �In the course of their employment(example:employee
Om:Ion/et % transporter-usually a van type vehicle or passenger car):or co
t` 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
i. i 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires. ` placarding(example:placards will be isplayed on the vehicle).y 2#
A 1 CARRIER NAME Z
I l u,,ai. ADDRESS D
w
Not To Scale I I CITY/STATE/ZIP 0
fr r1 _ i. i. i. i. MOTOR CARR.ID Interstate Intrastate
1 I r 1 1 / 1 ° Not in Comm./Govt. Not in Comm./Other
,_---- - -- I USDOT NO. ILCC NO. rn
XI
Source of above Z
. 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
co
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Black Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Adieu/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE