HomeMy WebLinkAbout2025-00005972 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0037O6742'
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INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ElB Injury and f or Tow Due To Crash YR 202512025-00005972 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 m
S LIBERTY ST El in10:40
® ❑ RELATED ®Y 0 N 01 28 2025 ®AM ❑YES ®NO U1 -<
_ _ g PRIVATE mo !day/yr ❑PM FLOW CONDITION m
FT!MI N E S W VILLA ST COUNTY PROPERTY ❑Y ® N DOORING ElV #OF MOTOR IR SLOW 1 (n
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0
Ig3 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑uuv ❑ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
0 4 /
yr 13-UNDER CARRIAGE 1a.1 2 ' 2 FIRE 0
NI E
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 0 m
M 2 4 SYTM❑Y ®S NE❑UNK VEH. O AT CRASH 0 15-99-UNKNOWN THER9 76•TOP 3 *Distraction Value 9 ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _iL S I,.4 COM VEH 0 E! 1 0
F• Elgin I L 60120 0 1 0 FIRST CONTACT 12 7_: _5 *II Yes.See Sidebar U1
Z 9 3216007B IL 2025 REAR
TELEPHONE
IL D 3GCUKRER1JG105229 allstate ❑Y ®N U2 M
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER RSUR m
99 9 Carbajal, Melissa 811350111 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 eu
N DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEOAL 0 EWES ❑m v 0 KCv ❑Dv
'1 9 9 1 Kia Motors CotIptima 2020' 00-NONE 11 12'-_, DUE TO CRASH ❑ 2
0 13-UNDER CARRIAGE 101 E FIRE 0 ® U2 C
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F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP 3 X
❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istraellon Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s iI s _4 COM VEH ❑ ® U1 CO
FIRST CONTACT 6 Y :j= _5 •If Yes.See Sidebar C
ELGIN IL 60120 0 1 0 BY78040 IL 2025 i0 Si)
IL 5XXGT4L33LG435536 none ❑Y ❑N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same none BAc E
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)!(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
2 3 09 /
2 O
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 El 11 1 11 r 81 ,025 10 40 ®❑pM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
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2 0 28 18 I r ❑PM• ❑Construction *
5
R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME
❑AM 0 Maintenance U2
-a, ARREST NAME Lopez Lopez,Jose De Jesus 11-601-Ax 486000182 ! r ID PM SLMT
o U 1 ® 11 1 CITATIONS ISSUED 0 PENDINGTIME ' 0 Utility
o NSECTION CITATION NO. ROADCLEARANCE 0 AM 30
t 2 El ARREST NAME Torres,Gloria 3-707 486000183 r 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
486-Munoz,Jasmine 301 31 / 12 r25 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 truckrtrailer -<
i- ;.____r__--; INDICATE NORTH combination):or
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_ 0• BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
r�. I - } (example:shuttle or charter bus):or 0
91 y I T,
I- I- --I--•--; I Not To Scale 1 - . - . transporting employened to es inthe course passengers5 or fewer thir emplod yment example:employee a contract
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arty s I. 'I ' w transporter-usually a van type vehicle or passenger car):or CO
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L L.___a____� IIIMOI. ! } •4. Is used or designated to transport between 9 and 15 passengers,including the driver.
for direct compensation(example:large van used for specific purpose):or
L i t i i. , 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). XI
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w — CARRIER NAME Z
1 1If . ADDRESS o
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I O
CITY/STATE/ZIP C)
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
--- --1 - USDOT NO. ILCC NO. m
XI
Source of above 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
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 Silver
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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE