HomeMy WebLinkAbout2025-00001646 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100 11h1
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY xoda5Dd194
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑$501-51,500 ❑ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500 ®NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
❑AMENDED YR 202512025-00001646 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 �I
® ❑ RELATED ®Y 0 N 01 08 2025 ®AM ❑YES ®NO U1 -<
S EDISON AVE Elgin08:52
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION ITl
FT!MI N E S W VAN ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 u)
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
lgi 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 EOUES 0 NW 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C)
0 2 !
yr 1t 12 0 ❑ ® E
13-UNDER CARRIAGE 10 2 FIRE 0 IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 gi U2 2 rr1
F 2 SY4 ❑Y ONM❑UNK VEH. O AT CRASH IN O 15-OTHER
99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8_iL e i 4 COM VEH 0 ix) 1 0
~ ELGIN I L 60123 0 1FIRST CONTACT 1 7_; __5 *II Yes.See Sidebar U1
Z 3851853B ' E
M TELEPHONE
IL D 0 1C6SRFJTXMN618811 None ❑Y ❑N U2 13 . m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Estefania.Jose. R. none 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 7]
m x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0!My 0 Ixv 0 Dv CIRCLE NUMBER(S) U1
!1 9 6 7 Mazda CX9 2009 00-NONE 012.._1 DUE TO CRASH ❑ 2 x
or 13-UNDER CARRIAGE 10 I 2 FIRE ❑ El U2 C
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3
❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN *Oistrac on Value g g
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-iI�1:, 4 COM VEH ❑ ® U1 CO
FIRST CONTACT 11 7 _, _5 ••If Yes.See SidebarC
F= ELGIN IL 60123 B 1 Q152931 IL I g
IL D JM3TB38A290177871 State Farm ❑Y ®N RDEF 73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 99 =
99 9 Same 3513538SFP13 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Other RESPOND 0 N U1 =
(UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 5 03 / F 9 4 0 1
m
/ / #OCCS D
/ / UI 2 D
/ / 1 0
U EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur El U2Z
N 1 CD 11 4 1/ ,/2 !25 11 50 ❑PM in a Work Zone? NJ N DIRP D
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t T 2 18 PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM
0 If YES check one below: U, 7 C)
2 ❑ I ! ❑PM, ❑Construction
R 1 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
-a, ARREST NAME Ocampo Tranquilano.Adelia 3-707 406003625 ! ! El PM SLMT
o N 1 ® 11 4 igi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility
AM 30
t 2 ❑ ARREST NAME Ocampo Tranquilano.Adelia 3-708 406003626 1 ! 0 PM ❑Unknown work zone type U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
547-Hometer.William 1/ , 8/ /025 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 truck trailer -<
c ` --I -' 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
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3. Is designed to carry 15 fewer passengers and operated a contract carrier O
I- L.__-A-.-.� transporting employees thecourse of their employment(example:employee
L. } } transporter po -us YpbY
T I AVO
y, nsportet wally a van type vehicle or passenger car):or CO
4. Is used or designated to transport between 9 and 15 C
ji } } g Po passengers,including the driver, to
- — — — — - for direct compensation(example:large van used for specific purpose):or O
L L--_-a-.... - t i i i. L 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m
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placarding(example:placards will be displayed on the vehicle). XI
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L L i . < l• --I
iMisrl I CARRIER NAME Z
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ADDRESS 0
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CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
----------1 - 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
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Form Number 0
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
0
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Red Black
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE