HomeMy WebLinkAbout2025-00000106 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q 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)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00000106 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 mN MCLEAN BLVD Elgin03:56
® ❑ RELATED ®Y 0 N 01 01 2025 ❑AM ❑YES ®NO U1 -<
_ _ PRIVATE mo !day/yr ®PM FLOW CONDITION m
FT!MI N E S W LARKIN AVE COUNTY PROPERTY El ® N DOORING ❑y #OF MOTOR 0 SLOW 15 u)
❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 MAU 0 wcv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 5 n
FOR DAMAGEDAREA(S) FRONT TOWED U1 Q
!1 9 5 5 Jeep(after 196 i0nd Cherokee 2000 00-NONE VI
13-UNDER CARRIAGE „' 12 IE
!-0 DUE TO CRASH ❑
� FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED 0 0 U2 5 M
F 2 SYTM IN ENGAGETHER
4 0 Y ®SNE❑UNK VEH. 0 AT CRASH 0 99-U15-UNKNOWN 9 16-TOP() ,Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 iI �I COM VEH 0 Ea 1 n
I— FIRST CONTACT 1 7 6_ --_;__5 *IIYes.See Sidebar Ut 0
Z ELGIN IL 60120 0 1 0 Z540418 IL 2025
TELEPHONE
IL D 0 1J4GW48S7YC336775 State Farm ❑Y Igl N U2 m
B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
co
Same 1188803 SFP 13 1 r
`o 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 0 EWES 0
!1 9 yr 7 Dodge Nitro 2010' 00-NONE O QI-O DUE TO CRASH ❑ 2
0 13-UNDER CARRIAGE 10( I 2 FIRE 0 ® U2 C
c
F 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
0 Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN `Distracion Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-iI�1:, 4 COM VEH ❑ ® U1 W
FIRST CONTACT 12 7 .5 •If Yes.See Sidebar
z E LG I N IL 60123 0 1 0 DY62386 IL 2025 REAR- 0 C
IL D 0 1 D4PU4GK3AW174955 American Alliance ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
Same I LAA-0800759-01 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND O N U1 =
KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 4 01 (O1 l2025 03 59 ®pm in a Work Zone? ®N DIRP co
1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 1 C)
T
0
2 0
06 2 ( ( ❑PM 0 Construction
Z3 0 I!!I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5
o 1 ® 11 4 ARREST NAME Andrade. Rosalva.0. 11-902 476000326 / ! El PM SLMT
I$!CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM• •
❑Utility
o f 2 0 ARREST NAME Andrade. Rosalva.0. 11-402-A 476000325 01(01 (2025 04 02 ®PM ❑Unknown work zone type U1 30
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? D Y 30
476-Ramos.Clarissa 602 01 ,21 (2025 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 -<
` ` ' ' r ir ® I. INDICATE NORTH combination):or .Z-1
I I I E BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i_ .:.. -:. j I I I - r r (example:shuttle or charter bus):or 0
`► 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier O
r }-----;----1 r 12 ,_ - . I- . transportingemployees In the course of their employment
�„ transportr-usuall a van type vehicle or passen car (orxample:employeew
L L.__-a-_- - — — — — — — — — - 4. Is used ordesi natedtotransportbetween9and15passengers,includingthedriver. N
1O } } }— — for direct compensation(example: arge van used for speific purose):or
L L--_-a--- - — — —j t - l. i. I 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m
_ _ _ placarding(example:placards will be displayed on the vehicle). XI
- -Lorkln?Aw — — — — D
1 [ CARRIER NAME
I A I I - ADDRESS 0I
I I CITY/STATE/ZIP n
1 1
No To Scele I - MOTOR CARR.ID 0 Interstate 0 Intrastate
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
------------ - USDOT NO. ILCC NO. rn
Xl
Source of above z
. 0 Yes I No ❑ Unknown 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 ❑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' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Silver Black
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ElNOT DISABLING DAMAGE DAMAGE EXTENT: 2 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