HomeMy WebLinkAbout2025-00002241 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 15
VEHICLE/PROPERTY ❑OVER 51,500 El NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00002241 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED PRIVATE ❑Y ®N 01 10 2025 DAM ❑YES ®NO U1 -<
N MCLEAN BLVD Elgin mo /day/yr 04:46 ®PM FLOW CONDITION m
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�O C.'J!MI N E O W M I LDRED Ave COUNTY PROPERTY ❑Y ® N DOORING El #OF MOTOR 0 SLOW 1 (n
Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 04 n
0 3 /
yr 13-UNDER CARRIAGE i FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O 2 DISTRACTED ❑ 0U2 04 r<n
M 2 SYTM IN ENGAGEDTHER
4 ❑Y ®SNEDUNK VEH. 0 AT CRASH 0 99-U15-UNKNOWN 016 3 `Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF D;i�6 �'.4 COM VEH 0 j$J 1 O
m P. ELGIN I L 601 23 0 1 0 FIRST CONTACT 9 7 : __6 •!ryes.See Sidebar Ut
Z EW81625 IL 2025 ' E
TELEPHONE
IL J N 1 EV7AR4LM256283 ALLSTATE ❑Y ®N U2 I''I
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Vargas. Lesley 811665820 3 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER
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m g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES 0 NMv 0 I V 0 DV
/1 9 9 4 Nissan Sentra 2015 00-NONE 'o,� t2 (,-2 FIRE DUE o CRASH ® U2 2 C
o Yr 13-UNDER CARRIAGE ID
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistractlon value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF �'i- 6 il;, 4 COM VEH D ® U1 CO
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FIRST CONTACT 7 Q __,�_6 •(ryes,See Sidebar
ELGIN IL 60123 0 1 0 EZ14768 IL 2025 I 0 N
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IL D 3N1AB7AP4FL676159 Unique ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same ILP3432289 BAc E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (DOBI (SEX) {SAFT) (AIR) OHM 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 3 05 /
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 01 !10 /2025 04 46 ®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 5 C)
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2 0 2 99 ! / ❑PM• ❑Construction
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R 3 0 $I CITATIONS ISSUED El PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM 0 Maintenance U2
oEl 11 1 ARREST NAME Tinajero.Joel.X. 11-901 1506-336 / / El PM SLMT
o N 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' 0 Utility
30
t 2 ARREST NAME AM
T El ! / ❑❑PM El Unknown work zone type U1
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1506-Nunez. Maria 501 02 ! 11 /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.
A CMV is defined asmotor vehicle used to transportand:
r ----,5-••--, ; any passengers or property
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1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
} i.-- -i-- --; } } } r -, , ; ; , 1, ( INDICATE NORTH combination):or —I
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BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ' i 1 , } (example:shuttle or charter bus):or
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3. Is L L.___A_. 1 i. <-- . -___� J transporting employened to es Inhecourse 5 or fewer o their eers mplod yment example:employeener X
} } }
transporter-usually a van type vehicle or passenger car):or 1:0
< <.__-a-_-_, , < <--_-a-___� , , , , 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver,
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L L___-a____.: L L L ...._-.�____� l. i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). XI
--I
CARRIER NAME Z
ADDRESS 0
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other O
USDOT NO. ILCC NO. m
XI
Source of above z
.
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'; 0 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' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Black White
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