HomeMy WebLinkAbout2025-00005559 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X0037055
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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 ®5501-51.500 0 ON SCENE 8
VEHICLE/PROPERTY ❑OVER 51,500 ®NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and for Tow Due To Crash YR 2025I 2025-00005559 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 r1
® ❑ RELATED 0 Y ®N 01 26 2025 ®AM ❑YES ®NO U1 -<
1620 VILLA ST Elgin08:40
_ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR ®SLOW 1 (n
❑ FT!MI N E S W Kane HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 NW 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 1 n
0Cruz Quintana.An elica 0 7 /
yr 13-UNDER CARRIAGE IE
10l ! 2 FIRE 0
EN
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ ]$I U2 1 r<rl
F 2 SY4 ❑Y ❑SNEM®UNK VEH. 6 AT CRAS IN H 5 15-OTHER
99-UNKNOWN 9 76•TOP 3 *Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ iII a ii,4 COM VEH 0 j$J 1 0
~ ELGIN IL 60123 0 1 0 FIRST CONTACT 6 7_;LQ--5 *II Yes.See Sidebar U1
V. Z CQ94624 IL 2024
TELEPHONE
IL D 5J6RW2H2XLL012936 State Farm ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 0736654SFP13 2 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 2 c
N DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED 0 PEDAL ❑EWES 0 NMv 0 Ncv 0 DV
!1 9 6 5 Kia Motors Cogorte 2023 00-NONE 11_"j ni-_, DUE TO CRASH ❑ 2 x
y yr
0 13-UNDER CARRIAGE 10( I FIRE ❑ ® U2 C
c
M 2 4 SYSTEM IN 6 ENGAGED 5 15-OTHER 9,16-TOP 3 X
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `0istracton Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s-il 6 I1:, 4 COM VEH ❑ ® U1 CO
FIRST CONTACT 12 7� .5 •(ryes.See Sidebar
H E LG I NZ IL 60123 0 1 0 DY23099 IL 2025 REAR C
M
IL D 3KPF54AD8PE643928 Auto Club ❑Y ®N RDEF 7J
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same AUT700799369 BAG $
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)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
E/ MOST EVNT LOS DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 10 5 01 ,26 /2025 09 00 ®❑PM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
2 ❑ 10 99
N 3 ❑ ❑CITATIONS ISSUED ID PENDING + / ❑PM ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 3
-a, ARREST NAME / / El PM '
o ® 10 5 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT
rAM
8 N 2 El NAME 1 / ❑❑AM ❑Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 05
558-Lara. _izette 401 , / 0 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.
A CMV is defined asmotor vehicle used to transportand:
r ----,5-••--, ; any passengers or property
Z
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
} i.-- -i-- --; } } } i- -, , ; ; , 1, ( INDICATE NORTH combination):or —I
p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ' i I , } (example:shuttle or charter bus):or
X
3. Is L L.-_------ 1 i. <--_- -___� J transporting employened to es Inhecourse 5 or fewer o their eers mplod yment example:employeener X
} } }
transporter-usually a van type vehicle or passenger car):or 1:0
< <.__-a-_-_- , < <--_-a-___� . , , , 4. Is used ordesi nated to trans rt between 9 and 15 passengers,including C} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or 0
L L---------_.: L L L ...._-..i._ ; l. i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). XI
—D7
CARRIER NAME Z
i.
ADDRESS 0
, n
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other 0
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 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
White Black
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE