HomeMy WebLinkAbout2025-00004978 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets _ 01111101111 01101100 0 n 111111111Oil
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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 ISI$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ❑OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and f or Tow Due To Crash YR 202512025-00004978 VEHT *
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 f1
N JANE DR El In03:15
® ❑ RELATED ' ' 0 N 01 23 2025 ❑AM ❑YES El NO U1 -<
g PRIVATE mo !day/yr ®PM FLOW CONDITION m
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FT!MI N E S W LARKIN AVE COUNTY PROPERTY El ® N DOORING ❑y #OF MOTOR IR SLOW 1 (n
❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
CK DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 C)
FOR DAMAGEDAREA(S) FROPtf TOWED U1 0Unknown.O. ! ! Unknown Unknown 00-NONE 012 , DUE TO CRASH 0
NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) EN
OD I. 2
9 9 SYSTEM IN 9 ENGAGED 9 99-OTHER O9 16-TOP 3 DISTRACTED 0 0 U2 3
❑Y ❑N CO LINK VEH. AT CRASH UNKNOWN O 4 `Distraction Value 9 ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF �1 COM VEH ❑ j$J 1 0
I- FIRST CONTACT 9 7_:—_6t-_5 *II Yes.See Sidebar U1
0 9 0 UNKNOWN REAR
2 Z
_ TELEPHONE
UNK. 8 UNKNOWN Unknown ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same Unknown 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
r D Y°®N 0
W K DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 IIIAV 0 KV 0 Dv
!1 9$9 Chevrolet Malibu 2019 00-NONE 11_. t2 FROM TOWED, DUE TO CRASH ❑ C 2 73
0mo 13-UNDER CARRIAGE O I 2 FIRE 0 El U2 C
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M 2 4 SYSTEM IN 0 ENGAGED 0 ®-OTHER 016-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF O'i' '!,_4 COM VEH 0 ® U1 co
F,,, FIRST CONTACT 9 7LJ_,-_5 ••Iryes.See Sidebar C
E LG I N IL 60123 0 1 0 DE90569 IL 202 REAR
0 N
IL D 0 1G1ZD5STOKF145256 State Farm ❑Y ®N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Gonzalez. Magdalena 13-6811-j47 BAC
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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 ❑Y U2 Z
N 1 ® 11 1 01 ,23 /2025 03 15 ®PM 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 ❑ 28 03
N 1 3 ❑ 0 CITATIONS ISSUED 0 PENDING ( 1 ❑PM- ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5
-a, ARREST NAME / / ❑PM '
oN ® 11 1 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT
r 2 ❑ ARREST NAMEAM
T ( / PM ❑Unknown work zone type 20
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n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ ❑AM Workers present? ❑Y 30
485-Quintana.Josue 602 334-Fries ( / ❑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
�____r____. I I _ INDICATE NORTH htrati rating more than 10,000pound (example:truckortruck/trailer
combination): -I
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N BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
I _ (example:shuttle or charter bus):or
Not To Scale ,I 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
I' I• I. transporting employees In the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or w
-- - } } 1 •4. Is used or designated to transport between 9 and 15 passengers,including the driver. N
for direct compensation(example:large van used for specific purpose):or o
5g i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
i placarding(example:placards will be displayed on the vehicle). XI
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6n1dn?A+n=I ` I r ` CARRIER NAME Z
L L L L L____x ADDRESS
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CITY/STATE/ZIP 00
MOTOR CARR.ID 0 Interstate ❑ Intrastate
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I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
;_---- ----., - USDOT NO. ILCC NO. m
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Source of above z
. MCS 0 Yes 0 No 0 Unknown Out of Service 0 Yes ❑No Z
Form Number 0
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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
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