HomeMy WebLinkAbout2025-00000553 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111 III 11 IIIIII Mil 01100 00 111111111111
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INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 3
VEHICLE/PROPERTY ®OVER$1,500
El NOT ON SCENE(DESK REPORT)
El AMENDED ElB Injury and f or Tow Due To Crash YR 202512025-00000553 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
S MCLEAN BLVD Elgin12:04
® ❑ RELATED ®Y 0 N 01 03 2025 ❑AM ❑YES El NO U1 -<
_ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION m
FT!MI N E S W LILLIANST COUNTY PROPERTY ❑Y ® N DOORING ICIy #OF MOTOR 0 SLOW 2 u)❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ® STOPPED U2 --I
E j 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 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 5 C)
FOR DAMAGEDAREA(S) FROf tf TOWED U1 Q
NAME(LAST,FIRST,M) Y mo
/1 9 8 3 Toyota Avalon 2003 00-NONE ,, • 12 0 DUE TO CRASH ❑ VI E
13-UNDER CARRIAGE 10 2 FIRE 0 IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 5 M
M 2 SY4 ❑Y ®SNE❑UNK VEH. O AT CRASM IN H O 99-UNKNOWN 9 76•TOP 3 `Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S_iL S i COM VEH 0 Ea 1 0
F.
Hanover Park IL 60133 0 1 0 FIRST CONTACT 1 7_; __5 *IIYes.See Sidebar U1
Z A163212 IL 2025 REAR
TELEPHONE
IL D 4T1 BF28BX3U309265 Allstate ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
99 9 Reyna.Jose. R. 811760034 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 XI
x DRIVER ❑ PARKED 0 DRIVERLESS ❑ FED 0 PEDAL ❑EWES 0 uv 0 NCv 0 Dv CIRCLE NUMBER(S) U1
!1 9 6 2 Jeep(after 19&',Idiator Rubicon 2020 00-NONE 'o,1 t2 c,�2 DUE O CRASH 0 ® U2 2 C
o yr 13-UNDER CARRIAGE
c
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9:1,6•Top
3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN POINT OF 8 t *Distraction Value 0
t 4 COM VEH D ® Ut CO
Q _,�_
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6
FIRST CONTACT 7 5 •If Yes.See Sidebar
Elgin IL 60120 0 1 0 2751023B IL 2025 REAR0
IL D 1 C6HJTFG 1 LL107218 State Farm ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 0436166sfp13 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 4 11 r 12 !25 12 04 ®PM AM in a Work Zone? ®N DIRP D
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1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
o"
2 10 28 1 / ❑PM ❑Construction *
5
R 3 ❑ $I CITATIONS ISSUED El PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
U2
ARREST NAME
Reyna. Benny. ❑R. 11-601 w1545-92 / ! ❑PM ❑Maintenance SLMT
®u 1 11 4 -
o N 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME0 AM
El Utility
MT
t 2 ElARREST NAME 11 112 125 12 05 ®PM ElUnknown work zone type U1 30
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ID - ❑AM Workers present? ❑Y 30
1545-VanEycke. Brier 602 r r 0 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
11 ® Z
ADDITIONAL UNITS FORMS.
r -- r••--, , A CMV is defined as any motor vehicle used to transport passengers or property and:
L_ .
1. Has a weight rating more than 10,000 pounds(example:truck or truck/trailer -<
i- i•-----I-----; I I I '*I I 1 Not To Scale J - combination):or —I
---- INDICATE NORTH p1
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 — — — — 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I 0
} } } transporting employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
< <.___a____.l 3 r - I. } } } •4. Is used or designated to transport between 9 and 15passen rs,includingthedriver,
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for direct compensation(example:large van used for specific purpose):or O
L i t i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D
— — — — placarding(example:placards will be displayed on the vehicle). ,Zmt
—I
f CARRIER NAME Z
II iii I ADDRESS O
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0 ?Q� CITY/STATE/ZIP 0
I 1. I - MOTOR CARR.ID 0 Interstate 0 Intrastate
1
I I I ❑ Not in Comm./Govt. 0 Not in Comm./Other
:- -----------1 -
I USDOT NO. ILCC NO. m
73
Source of above z
. Form Number
m
Xl
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
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LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Silver Red
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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE