HomeMy WebLinkAbout2025-00003522 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets III 11 IIII
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XO036.,8263
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INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ElS501-S1,500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER 31,500 El NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
0 AMENDED YR 202512025-00003522 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED PRIVATE ❑Y ®N 01 16 2025 ❑AM ❑YES ®NO U1 -<
S STATE ST Elgin mo /day/yr 04:22 ®PM FLOW CONDITION Ill
®15 ®!MI 0E S W Washburn St COUNTY PROPERTY 0 Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD DO
U2 --I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
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 2 n
Ayala.German 0 5 /
yr Ford Fusion
13-UNDER CARRIAGE 101 2 VI E
FIRE 0 IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 Ea U2 2 m
M 2 SYis-OTHER
4 ❑Y ®SNE❑UNK VEH. O AT CRASH M IN ENGAGEDO 99-UNKNOWN 9 76•TOP 3 *Detraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 ;i�6 �i 4 COM VEH 0 Ea 1 0
~ ELGIN I N I L 60123 0 1 0 FIRST CONTACT 1 7 ; __5 *II Yes.See Sidebar U1
ZDZ77220 IL 2025 REAR
TELEPHONE
IL D 0 3FAHP08Z29R196723 StateFarm ❑Y IlN U2 I-
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire Same 0931893SFP13 1 1—
"6 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y ® N 2 c
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x DRIVER ❑ PARKED 0 DRIVERLESS ❑ FED ❑PEDAL ❑EWES ❑NIAV 0 NOV ❑DV
1 91'<4 Honda Accord 2014 00-NONE 111 12 (_2 FIRE DUE OCRASH 0 ® U2 2 C
...
- 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 ••Distraction Value 9 U1 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 �_ 6 j:;_4 COM VEH ❑ El W
I- FIRST CONTACT 7 Q _,L_5 •If Yes.See Sidebar
Z Aurora IL 60505 C 1 0 V991801 IL 2025 I0 Si)c
M
IL D 0 1 HGCR2F34EA22717 Allstate ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 932542765 BAc $
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),(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 1 11 ,61 ,025 04 22 ®AM in a Work Zone? ®N DIRP co
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
2 0 28 99 11 ,61 ,025 04 23 ®PM ❑Construction
F
R O 0 ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
3 ❑AM ❑Maintenance U2
o ® 11 1 ARREST NAME Ayala.German 11-601-Ax 1530000229 11 ,61 r025 04 28 Igi pM SLMT
o N -
0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility
0 AM
t 2 El ARREST NAME 11 +61 1025 04 43 ®PM El Unknown work zone type U1 3O
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1530-Soto.Oscar 701 21 , 12 ,25 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 tO50A
ADDITIONAL UNITS FORMS.
r ----r•---, , I A CMV is defined as any motor vehicle used to transport passengers or property and: Z
r 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
i- ;----;-----; Unit 1 _ : combination):or -I
_ r INDICATE NORTH p1
0
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ (example:shuttle or charter bus):or C)
• 3. Is designed to carry 15 or fewer passengers and operated a contract carrier 0
Not To Scale f } } 1- transporting employees In the course of thir employment(example:employee
I I
L'"`1 I I I transporter-usually a van type vehicle or passenger car):or w
ICI C
-- I. } 1. •4. Is used or designated to transport between 9 and 15 passengers,including the driver, to
�+ for direct compensation(example:large van used for specific purpose):or o
Unit 2 Washburn?St _ i i L 5. Is any vehicle used to transport an hazardous material(HAZMAT)that requires m
Y
placarding(example:placards will be displayed on the vehicle). XI
— — — —
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CARRIER NAME Z
r r :- :- :-- --:-
ADDRESS 'n
C)
CITY/STATE/ZIP
MOTOR CARR.ID ❑ Interstate ❑ Intrastate
I I T I Not in Comm./Govt. Not in Comm./Other
S?State?St � � � ❑ ❑ o
---"-1 USDOT NO. ILCC NO. C
m
XI
Source of above z
'
. MCS 0 Yes 0 No 0 Unknown Out of Service 0 Yes ❑No 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' -n
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Blue,Dark Gray
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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE