HomeMy WebLinkAbout2025-00004708 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets IIIIIII III II IIIIII I011011000
DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003 066803
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 15
VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00004708 VEHT *
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
® ❑ RELATED 181 Y 0 N 01 22 2025 ®AM ❑YES ®NO U1 -<
E CHICAGO ST Elgin 11:05
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION III
FT N E S W BODE RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 3 Cl)
❑ Cook HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FOR DAMAGEDAREA(S) FRO T TOWED U1 Q
NAME(LAST,FIRST,M) Martinez. Maria.O. mo 0 6 / /1 9 yr
4 Nissan Sentra 2015 00-NONE „_ O i_, ODE TO CRASH ❑
EN
13-UNDER CARRIAGE 10 ' 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 rn
F 2 4 ❑Y ® n 15-OTHER
SYSTEM
❑UNK VEH. ATCRASHD 99-UNKNOWN 9 16•TOP 3 `Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S,_iL S 4 COM VEH 0 Ea 3 C)
~ ELGIN I L 60123 0 1 0 FIRST CONTACT 12 7 ; _-5 *II Yes.See Sidebar IA
Z ED73602 IL 2025
TELEPHONE
IL D 0 3N1AB7AP9FY244380 Farmers Ins ❑Y ®N U2 nni
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Other 1 99 9 Same 542978839 3 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 3 2 eu
g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑r uv 0 NOV ❑DV
/1 9 6 6 Chevrolet Express 2015 00-NONE 10 1 t2 (,-2 DUE O CRASH 0 ® U2 7 C
o mo Yr 13-UNDER CARRIAGE
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X
❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN `0istraellon Value 9 0
POINT OF 8 i1 6 ,',„ COM VEH D ® U1 W
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6
FIRST CONTACT 5 7 -_,SOS •If Yes.See Sidebar
Burlington IL 60109 0 1 0 M207897 IL 2025 I 0
IL B 0 1 GCZG H FG2G 1273743 self insured ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
Other 1 99 9 U-46 self insured BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (D081 (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 6 03 /
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/ / UI 3 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 4 01 (22 /2025 11 05 ®p PM AM in a Work Zone? ®N DIRP D
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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
0
2 11 18 ( / ❑PM• ❑Construction *
Z 3 ❑ 1!>I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM ❑Maintenance U2
o1 ® 11 4 ARREST NAME Martinez. Maria.O. 11-1427-H- 324-(W)1434 / / El PM SLMT
o N •
0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
T 2 ❑ ARREST NAME AM
7 ( / pM El Unknown work zone type 30
U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ - El Am Workers present? CI Y 30
324-Phillos.James 302 / / ❑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
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1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
} i.-- -i-- --; } } } r -, , ; ; , 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 1 , } (example:shuttle or charter bus):or
X
3. Is L L.___A_. 1 <-- . -___� 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 03
< <.__-a-_-_, , l• < <--_-a-___� , , , , 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or 0
L L___-a____.: L L L ...._-..:_____� t 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
--I
CARRIER NAME Z
ADDRESS 0
T.
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other O
USDOT NO. ILCC NO. m
XI
Source of above z
If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. Xl
Xl
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's Z
own tank)? 0 Yes 0 No 0 Unknown
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes 0 No 0 Unknown g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash? A
❑ Yes II El Unknown C
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
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Black White
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