HomeMy WebLinkAbout2025-00004547 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II 1 III 11 II I1 II 11111111
DDI II
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV XO037OO957*
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 8
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00004547 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 mLILLIAN ST Elgin 04:03
® ❑ RELATED ®Y 0 N 01 21 2025 ❑AM ❑YES ®NO U1 -<
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION MFTlMI N E S W S MCLEAN BLVD COUNTY PROPERTY ❑Y 21N DOORING ❑y #OF MOTOR 0 SLOW 1 0)0 Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
® 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 EWES 0 uuv 0 icy ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) y N 4 n
Q
NAME(LAST,FIRST,M) Tamez.Jessie. M. mo yr
Jeep(after 19B rokee 2019 00-NONE ® 12 , CUE TO CRASH ❑ EN
13-UNDER CARRIAGE 10 1 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 4 <<n
F 2 4 SYTM❑Y ®SNE❑UNK VEH. 0 AT CRASH 0 15-99-UNKNOWN THER9 16•TOP 3 *Distraction Value 9 ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF iL 6 1, 4 COM VEH 0 0 1 0
ELGIN I L 60120 0 1 0 FIRST CONTACT 11 7_: __5 *rives.See Sidebar U1
ZES71433 IL 2024 REAR
TELEPHONE
IL D 0 1 C4PJ M BXXKD199860 Geico ❑v ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 6162 42 88 22 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 2 eu
x DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED 0 PEDAL 0 EWES 0 uv 0 NCv 0 Dv
1 9 yr 1 Chevrolet Cruze 2014 oo-NONE ,i ' t2 DUE TO CRASH 0 2
0 13-UNDER CARRIAGE FIRE ❑ ® U2
c
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOPO3
❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN 0istraetlon Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-it 6 1( 4 COM VEH D ® U1 COFIRST CONTACT 1 7�. _,__5 •If Yes.See Sidebar
= ELGIN IL 60124 0 1 0 ZV19842 IL 2024
IL D 1 G 1 PC5SBXE7236177 Allstate ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 974465577 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (DO81 (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 3 1 0 / M 2 3 0 1 0
m
/ / #OCCS D
71
/ / u1 2 D
/ / 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 , 11 ,025 04 03 ®pm in a Work Zone? ®N DIRP co
1 t PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 8 n
T
0
2 ❑ 2 06 , , 0 PM ❑Construction
Z 3 ❑ Igi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
a1 ® 11 1 ARREST NAME Tamez.Jessie. M. 11-901 1538000103 , / El PM SLMT
o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' 0 Utility
❑ 30
t 2 El ARREST NAME AM
T ! r ❑PM 0 Unknown work zone type U1
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 30
1538-Estrada. Leticia 600 334-Fries 31 , 12 ,25 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••--, ; 0A CMV is defined as any motor vehicle used to transport passengers or property and: Z
mN 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
- }____r__--; r. t combination):or —I
6 Not To Scale I INDICATE NORTH P1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ } (example:shuttle or charter bus):or
T,
L co3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
- t } } } transporting employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or co
} 4. Is used ordesi natedtotrans rtbetween9and15passengers,includingthedriver,
C
tr } } for direct compensation(example:large van used for speific purose):or 0
L L-------- p 4' t i. i i L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
/ ` < < placarding<1 4 (example:placards will be displayed on the vehicle). D
-1
_ CARRIER NAME Z
73 Lilliant O
ADDRESS
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oa obi. i. 4. C)
CITY/STATE/ZIP g
eo - MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
‘I. - --, - USDOT NO. 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 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Black Blue
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/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE