HomeMy WebLinkAbout2025-00002898 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 4 Sheets II
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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 ❑5501-51,500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT) El B Injury and f or Tow Due To Crash
0 AMENDED YR 2025I 2025-00002898 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED ®Y ❑N 01 13 2025 DAM ❑YES ®NO U1 -<
LARKIN AVE Elgin08:47
g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT N E S W N MCLEAN BLVD COUNTY PROPERTY ❑Y ® N DOORING ❑v #OF MOTOR 0 SLOW 1 (n
❑ Kane HIT ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
® &RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑Ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
0 5 /
yr 13-UNDER CARRIAGE 10 IE
�. 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 0 m
M 2 SYTM IN ENGAGEDTHER
4 ❑Y ®SNE❑UNK VEH. 0 AT CRASH 0 99-Uis-UNKNOWN 9 16-TOP® `Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6, it 6 jl COM VEH 0 Ea 1 n
F. FIRST CONTACT 3 7__c--_;-_5 *If ves.See Sidebar U1 0
Z ELGIN IL 60123 0 1 0 G352770 IL 2020 REAR
TELEPHONE
IL D 0 1 FM FK16528LA28644 Country Financial ❑v Igl N U2 I-
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Amaro.Teodoro P12A3248849 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 2 ou
g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑NMV ❑ GVN ❑Dv
1 9 9 5 Toyota Corolla 1997 00-NONE 11_"1 Qr O DUE TO CRASH 0 D 2 x
oYr 13-UNDER CARRIAGE 10( I. 2 FIRE 0 ® U2 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 *OistractIon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-iI�:,-4 COM VEH ❑ ® U1 W
FIRST CONTACT 12 7 .5 •If Yes.See Sidebar
z ELGIN IL 60123 0 1 0 DK31695 IL 2025 RFJ 0 C
IL D 0 1 NXBA02E7VZ649658 State Farm ❑Y ON RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire Villegas.Jesus 1440274-SFP-13 BAG E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((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 01 ,13 ,2025 08 47 ®AM 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 3 n
T
0
2 0 2 99 , ) ❑PM- ❑Construction X
7
Z 3 ❑ I!!I CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2
a ® 11 4 ARREST NAME Amaro. Melvin. M. 11-901-A S1529-000252 / r El PM SLMT
o N
0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' El Utility
0 AM r 2 El ARREST NAME 01 r 13 r2025 09 09 ®PM El Unknown work zone type U1 30
n T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 El1529-Audi red.Jonathan 601 334-Fries 02 ,04,2025 09 00 D PM Workers present? ®N U2 30
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
combination):or -<
i- --__r-_--; McLean?Blvd. —I
INDICATE NORTH p1
A BY ARROW 2 Is used or designed totran ortmorethan15 C
i_ i., -:. i 11 1 N.I I N ,. (example:shuttle or charter bus): passengers including the driver
or 0
3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
} } } transporting employees in the course of their employment(example:employee 72
,lit'.
I transporter-usually a van type vehicle or passenger car):or w
L L.___a__..� C
4. Is used or designatedtotrans rtbetween9and15passengers,indudingthedriver,I. } } for direct compenation(examp large van used for speific purose):or 0
I I I 4�j O
L--__A_---; Unit 2 — — - i. < i. L 5. Is anyvehicle used to transport anyhazardous material(HAZMAT)that requires
1 1 placarding(example:placards will be displayed on the vehicle). m
1 — — — — CARRIER NAME Z
Larkin?Ave. ADDRESS
w
Not To Scaler 0 CITY/STATE/ZIP
- i. 4. MOTOR CARR.ID 0 Interstate 0 Intrastate
I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other
----------1 USDOT NO. ILCC NO. m
XI
Source of above z
. IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No =
TRAILER VIN 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 0 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Black White
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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE