HomeMy WebLinkAbout2025-00004351 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 4 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003700919
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 2025I 2025-00004351 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 E1
168 RT20 EB Elgin 05:48
® ❑ RELATED ❑Y ®N 01 20 2025 ❑AM D YES ®NO U1 -<
_ PRIVATE mo /day/yr ®PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 cn
❑ FT/MI NESW 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
Qg3 DRIVER 0 PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES ❑NIAV ❑!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FOR DAMAGED AREA(S) FROf'rr TOWED U1 Q
Thomas.Jewell. L. 1 1 /
yr 13-UNDER CARRIAGE ) 1! FIRE 0
NI STREET ADDRESS SEX SAFT AIR AUTOMATION IN n ENGAGED n 15-OTHER
LEVEL LEVEL 14-TOTAL(ALL) VI
1U O DISTRACTED ❑ Ea
2 M252 M 2 4 ❑Y SYSTEM
❑UNK VEH. AT CRASH 99-UNKNOWN 9 76•TOP 3 ,Distraction Value 9 ALGN 2
CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST NT OONTACT 14 O 1L S-1tf O5 CIIOMs See Sidebar VEH !� U1 1 0
Z E LG I N I L 60120 0 1 0 D P80543 I L 2025 1REA 0
TELEPHONE
IL D 0 1 HGFA15519L027089 n/a ®Y ❑N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same n/a 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 2 0
m x DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑Nov 0 KCv 0 DV
/1 9 8 1 Chevrolet Cruze 2012 00-NONE ,t"i 12--_, DUE TO CRASH ❑ tSI 2
.. 13-UNDERCARRIAGE 10;1 2 FIRE ❑ ® U2 C
c
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X
❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistraglon Value 9 g
POINT OF s i ^�I� 4 COM VEH ❑ ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 15 TA-MI'OS •)ryes,See Sidebar C
= PINGREE GROVE IL 60140-9160 0 1 0 EZ12194 IL 2024 I Si)0
�
IL D 0 1 G1 PC5SH7C7392744 First Chicago Insurance ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Talavera Garcia, Ma Felicit ILS1061434-00 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(A.DDRESS)!(TELEPHONE! (EMS) (HOSPITAL)
2 6 09 /
:A
/ / UI 1 D
/ / 3 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 24 1 01 ,20 /2025 05 48 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 ® 11 1 04 28 01/20 /2025 05 49 pM
® • ❑Construction *
R O 0 El CITATIONS ISSUED El PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
3 ❑AM ❑Maintenance U2
a ® 11 1 ARREST NAME Thomas.Jewell. L. 11-601 1538000101 01/20/2025 05 54 Igi pM• • 0Utility SLMT
ISI CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM
r 2 El ARREST NAME Thomas,Jewell. L. 3-707 1538000100 01/20 /2025 06 55 ®PM ❑Unknown work zone type U1 45
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 45
1538-Estrada, Leticia 700 03 /04/2025 01 30 ®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 -
i- }--_.r-_--; combination):or -I
Not To Scale I INDICATE NORTH p3
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ } (example:shuttle or charter bus):or
S?State?St T`
L A 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 X
transporter-usually a van type vehicle or passenger car):or w
L L.___a__ 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including C} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or
L -a-___.l t l. L 1 L 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). m
E7ROUb?20 '>
I ree I' : I• I-- --I-
u'R2 CARRIER NAME
ADDRESS 0
rn
W?Rout'?20
I CITY/STATE/ZIP g
MOTOR CARR.ID ❑ Interstate ❑ Intrastate
I Cil USDOT NO ❑ Not in Comm./Govt. Not in Comm./Other 00
--- I ILCC NO. m XI
Source of above z
. 0 Yes II 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 0 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' -n
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Gray Silver
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
Arties/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Arties/Impound.Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE