HomeMy WebLinkAbout2025-00008539 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100 VI 1111111hi 11100
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 2025I 2025-00008539 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m
SHALES PKWY Elgin
® ❑ RELATED t3I Y 0 N 02 08 2025 DAM ❑YES E)NO U1 -<
PRIVATE mo /day/yr 07:44 ®PM FLOW CONDITION ITT
030 ®/MI N E O W Walden Dr COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 1 (n
Cook HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I
El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
�i DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 C)
FOR DAMAGEDAREA(S) FROf4r TOWED U1 Q
NAME(LAST,FIRST,M) Unknown.O. mo / / yr Unknown Unknown 00-NONE 11;. O I_1 DUE TO CRASH ❑
EN
13-UNDER CARRIAGE 10 ' 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 4 rn
SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3
9 9 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s_iL S �i,4 COM VEH 0 j$J 1 0
~ 0 9 FIRST CONTACT 12 7_; _5 *lI Ves.See Sidebar U1
REAR
2 Z ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 11/
Unknown ❑Y ❑N U2 I—
.5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same Unknown 2 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
r D Y°N❑l N
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N DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 ivy 0 NOV 0 DV CIRCLE NUMBER(S) U1
/1 9 y 5 Toyota Camry 2002 00-NONE 11 j 12..-_, DUE TO CRASH ❑ 2 73
0 13-UNDER CARRIAGE 10'( 2 FIRE ID ® U2 C
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F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN `0istrac on Value g g
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 1 S --4 COM VEH D ® ut CO
FIRST CONTACT 6 O7 ,�=Q)OS •IfYes.SeeSidebar C
ELGIN IL 60120 0 1 0 MA7539 IL 2025 FIRST
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IL D 0 4T1 BF30KX2U026185 Liberty Mutual ❑Y ®N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Vargas.Jose. L. AOV-248-622513-4016 SAC E
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)
2 3 01 /
2 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 02,08 /2025 07 44 ®pm in a Work Zone? NJ N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
2 0 28 18
N 3 0 ❑CITATIONS ISSUED 0 PENDING + / ❑PM• El Construction
SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM 0 Maintenance U2
-a, u ARREST NAME / / ID PM '
1 ® 1 1 1UtilitySLMT
o SECTION CITATION NO. ROAD CLEARANCE TIME 0
❑CITATIONS ISSUED PENDING
El AM
r 2 ElARREST NAME 02/08 /2025 07 44 ®PM ElUnknown work zone type U1 30
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 1542-Chase. Ethan 302 - , / ❑❑PM Workers present? ®N U2 30
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 truck trailer -<
J
` ` -' r INDICATE-' NORTH combination):or .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- (example:shuttle or charter bus):or
X
L I------..-----: Not To Scale 3. Is desgned to carry 15 or fewer passengers and operated by a contract career I O
- } } } transporting employees In the course of their employment(example:employee 73
transporter-usually a van type vehicle or passenger car):or w
L L.___a.. 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including C} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or O
L t ii. , 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
® �1 unna placarding(example:placards will be displayed on the vehicle). .Z1
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CARRIER NAME Z
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Ii. i. i. i. ADDRESS D
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4.
CITY/STATE/ZIP 0
unnr
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
; _Y_ _-1 - 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
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
Red Red
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: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE