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HomeMy WebLinkAbout2025-00078761 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I0110 II II III IIIIII*I III IIIIII DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X 4019604 u, 1 U21 2 4 1 U1 2 U2 1 U1 1 U2 1 U1 1 U2 1 1 14 U, 1 U2 1 *P 0119 INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S ❑$501-51.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash El AMENDED YR 202512025-00078761 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 �I ® ❑ RELATED ®Y ❑N 12 11 2025 ®AM ❑YES ®NO U1 JEFFERSON AVE Elgin10:03 _ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m FT!MI N E S W N GROVE AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ® FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 1 1 FOR DAMAGEDAREA(S) FRO t TOWED U1 0 / ! Dodge Ram 1500(pickup) 2007 00-NONE ©, 12 , DUE TO CRASH 0 NAME(LAST,FIRST,M) Nieves.Jose.J. mo yr g 13-UNDER CARRIAGE 9 I I! 2 FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 ]$I U2 2 m M 2 4 Y SYSTEM IN ENGAGED 15-OTHER 9 s6.TOP 3 9 ALGN = ❑ ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, i�6 �i COM VEH ❑ Ea 1 0 0 ELGIN IL 60120 0 1 FIRST CONTACT 11 7_: __5 *Ilyes.SeeSidebar U1 Z 4128284 IL 2026 E TELEPHONE IL D 1 D7HA18247S100683 Progressive ❑v Igl N U2 Si . m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same 864977325 3 1— "6 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused 0 Y ❑ N 2 0 m g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑row 0 CIRCLE NUMBER(S) U1 KDV ❑DV 2 O 0 6 Nissan Sentra 2012 00-NONE 11-.. 12 0 DUE TO CRASH 0 D 2 o Yr 13-UNDER CARRIAGE 10 1 i., 2 FIRE ❑ ® U2 C M 2 4 0 Y El SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 9 X N 0 UNK VEH. AT CRASH 99-UNKNOWN *Oistrac on Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-it 6 1l, 4 COM VEH ❑ ® U1 CO FIRST CONTACT 1 Y _,__5 •(ryes,See Sidebar = ELGIN IL 60120 0 1 A434197 IL 2021 I 9 Sn IL D 3N 1 AB6AP3CL641604 Progressive ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X Corona.Jose.T. 976618878 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) U2 996 r m ##occs y / ,, U1 1 D 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 1 12,11 r2025 10 03 ®❑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 OT 2 0 23 23 N 3 0 0 CITATIONS ISSUED CI PENDING + r ❑PM• ❑Construction >E SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM ❑Maintenance U2 —a, ARREST NAME / / ❑PM ' o N ® 11 1 ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ,_,Utility SLMT 30 t 2 0 ARREST NAME AM 7 1 r ❑❑PM 0 Unknown work zone type U1 n OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 - ❑AM Workers present? ❑Y 30 387-Root. Mark 102 , r ❑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- }__-_r_-_-; 0 combination):or INDICATE NORTH BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver I a _ (example:shuttle or charter bus):or 531 r r r r ers nd a contract 030 L. ___� I NOt TO .SCa�9 transportingemployeeslinthecourseeo theiremaployment example:employeener } } } tra3.nsporter-usually a van type vehicle or passenger car):or L L.___a.._.� L 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including iefii N } } for direct compensation(example:large van used for specificpurpose):or [he driver, .�. Pe ( P 9 Pe or L i..._.a....� i .3 i ._ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires D �^"�— placarding(example:placards will be displayed on the vehicle). XI ' I' -1 CARRIER NAME Z I . ADDRESS 0 D rn I O CITY/STATE/ZIPg �. MOTOR CARR.ID 0 Interstate 0 Intrastate I . ❑ Not in Comm./Govt. 0 Not in Comm./Other --- --1 USDOT NO. ILCC NO. m XI Source of above z . • m 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 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 Red Silver 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