HomeMy WebLinkAbout2025-00081554 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X�08,386
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INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 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 2
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 2025I 2025-00081554 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 m
200 N GROVE AVE Elgin08:59
® ❑ RELATED ❑Y ®N 12 28 2025 ®AM ❑YES ®NO U1 -<
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION Ill
PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW Cl)
❑ FT/MI NESW Kane HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 --1
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
0 4 /
yr 13-UNDER CARRIAGE 10 !�. 2 FIRE 0
IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL O4-TOTAL(ALL) DISTRACTED 0 0 U2 m
M 2 4 ❑Y ®Nn 15-OTHER
SYSTEM
❑UNK VEH. AT CRASHD 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s_iL B 4 COM VEH 0 j$J 4 0
0
ELGIN N I L 60123 0 1 0 FIRST CONTACT 99 7_; _5 *Ilyes.See Sidebar U1
Z 3038617B IL 2026 REAR
TELEPHONE
IL D 0 1 FTZR15E41 PA45801 NO INSURANCE ❑Y ®N U2 51 . m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
co
Elgin Fire Gasca-Gaytan. Fabian NO INSURANCE 2
o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER r
2
❑ DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0
yr 12 _ C1
o 13-UNDER CARRIAGE t�.i :., FIRE ❑ 0 U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 0 0 SPDR 0
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistrac) n Value U1 9 -
POINT OF 8 - 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT Y ='+:-5 •COMI sVSee •Sidebar❑ ❑ C
CO
F` ---- co
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O
❑Y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
BAC
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
RESP❑YD❑N NDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0
/ / U2 r
m
Pj
/ / U1 1 D
/ / 0
EV MOST EVNT DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 0 2 3 12,28 l2025 08 59 ®❑pM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1
2 ® 1 3 11 15 12/28 /2025 08 59 PNl
❑ ❑Construction *
R t O 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME
3 ®AM ❑Maintenance U2
-a, ARREST NAME Gasca.Angelo.A. 11-1427-H- 456-439(W) 12/28/2025 09 06 ❑PM SLMT
o u 1 ❑ ig!CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM® 35
• ❑Utility
t 2 0 ARREST NAME Gasca.Angelo.A. 3-707 456-438 12/28 /2025 09 30 ❑PM 0 Unknown work zone type U1
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y
2 3 0 - CI Am Workers present? ❑
456-Romalo.Carmine 101 01 ,20/2026 ❑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 -<
c ` -' -' 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 1 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O
ta?Ave - } } } transporting employees in the course of their employment(example:employee X
1 transporter-usually a van type vehicle or passenger car):or w
' . 4. Is used or designated to transport between 9 and 15 passengers,including rCjt
i. <.__-a__-_� �,mrasu..r I } } } g po passen rs,includi [hedrNer,
for direct compensation(example:large van used for specific purpose):or
L L--_-a-___. Y — — — — — — — - l. i. i. ._ 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). ,Zmt
o* CARRIER NAME Z
—� I _ Net To Scale f - __ ADDRESS O
CROOrroeIauamrra. w
CITY/STATE/ZIP 0
0
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other
i- --- --1 - USDOT NO. ILCC NO. m
XI
Source of above z
. If Yes,Name on placard 0
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
0
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U_COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Blue
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U_DUE ETOO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO:
DUE T VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE