HomeMy WebLinkAbout2025-00081535 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 8 Sheets 01111101111
I0110 II 1111 101 1111 011111 I II
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004097053
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
El AMENDED YR 2025I 2025-00081535 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
973 LARKIN AVE El In04:04
® ❑ RELATED ❑Y ®N 12 28 2025 ®AM ❑YES ®NO U1 -<
_ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW Cl)
❑ FT/MI N E S W 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
Qg3 DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEOAL 0 EDUES 0 NIA/ 0 ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
0 8 /
yr
Kia Motors Co o 2016 00-NONE Q• �I• 0 DUE TOCRASH ® ❑
13-UNDER CARRIAGE tU 2 FIRE ❑ I <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 23 U2 rn
M 9 SY is-OTHER
4 ❑Y ®SNE❑UNK VEH. O AT CRASIN H O 99-UNKNOWN 9 t6•TOP 3 `Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s,;il a 4 COM VEH ❑ Ea 1 0
~ ELGIN I L 60123 0 1 0 FIRST CONTACT 12 7 ;1 _5 *elves.See Sidebar Ut
ZFB98970 IL 2016 Ismi
TELEPHONE
IL D 7 KNADM5A37G6638908 American Alliance ❑Y Il N U2 ni
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same I LAA-1114210-00 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ❑ N 2 ou
0 DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0 i v 0 DV
yr 12 _ 71
.. 13-UNDER CARRIAGE 10 I 2 FIRE ❑ ❑ U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 ❑ 0 SPDR 0
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraglon Value U1 9 -
POINT OF s-.;, 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT Y.='+:=5 COM•I sVEH See •Sidebar❑ 0
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M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O
❑Y ❑N RDEF73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER I =
BAC
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 997 <
RESP❑YDNDER❑N U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0
W 05 /
DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 0 1 2 Nelson. Barrett. M. Wooden Fence 12!29 /2025 04 04 ®❑pM AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 ,,
Si 2 CO 39 5 973 LARKIN AVE ELGIN IL 60123 28 19
/ ! ❑PM, ❑Construction >F
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Z3 ❑ Igi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2
-a, ARREST NAME Flores Balan.Gervin•T. 3-414 747658 ! r El PM SLMT
o u 1 ❑ B!CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM ❑Utility
t 2 El ARREST NAME Flores Balan.Gervin.T. 11-so1-Ax 747657 12!29 l2025 08 15 [M PM ❑Unknown work zone type U1 30
n 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y
467-Banks. Hannah 601 360-Yucaitis 01 !30 l2026 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 truckrtrailer -<
` ` --I -' I. INDICATE NORTH combination):or .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
® vot 7o score i - } (example:shuttle or charter bus):or 0
I 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O
I- I- -A-----I
} } } transporting employees In the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or w
< <.___a____.I N.1[leW AVv. } } 1. •4. Is used or designated to transport between 9 and 15 passengers,including the driver. N
I 1 II for direct compensation(example:large van used for specific purpose):or O
L __i_. . / - l. i. i I 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
LorkkOkve ���1. _ placarding(example:placards will be isplayed on the vehicle). XI
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CARRIER NAME Z
, ,J M.. ADDRESS D
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IV)
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CITY/STATE/ZIP 0
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
I. --- --4. - USDOT NO. ILCC NO. rn
XI
Source of above 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?
❑ Yes II No ElUnknown 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
to
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_COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 2 TOWED BY/TO.
_Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U_TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO:
DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE