HomeMy WebLinkAbout2025-00008837 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100 VI
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003720633
u, 9 U2 1 1 1 u, 2 U2 1 U199 1_12 U,99 U2 99 1 9 U1 1 U221 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 ❑ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500
®NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00008837 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 71
606 ILLINOIS AVE Elgin03:30
® ❑ RELATED ❑Y ®N 02 09 2025 DAM ❑YES El NO U1 -<
_ PRIVATE mo /day/yr ®PM FLOW CONDITION MCOUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 15 u)
❑ FT/MI NESW Kane HIT ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I
&RUN
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Qg3 DRIVER I] PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
/ / FOR DAMAGEDAREA(S) FRONT TOWED U1 0
Unknown.O. Unknown Unknown 00-NONE „ 12 , DUE TOCRASH ❑ EN
NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 191 !�. 2 FIRE 0 IE <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ]$I U2 m
SYSTEM IN ENGAGED 15-OTHER 9 le-TOP 3
9 9 ❑Y ID N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN =
$ 4 COM VEH 0 ZgJ
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF -,I[S !i,_ 1 00
I- 0 9 FIRST CONTACT 99 7_; _5 *II Yes.See&debar U1
REAR
2 Z ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1)
unknown 0 Y 0 N U2 I-
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
co
99 9 Same unknown 9 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y ❑ N 99
m ❑ DRIVER X. PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 IIIAV 0 KCv 0 DV
yr 10'j t2 (, 2
o13-UNDER CARRIAGE FIRE 0 El U2 C
-
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN 0 ENGAGED 0 15-OTHER a.IS 3 0 ® SPDR 0
❑Y ®N DUNK VEH. AT CRASH 99-UNKNOWN ••Distraction Value 9 U1 0 -
POINT OF s- 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6 j�',_ COM VEH D ® CO
F,,, FIRST CONTACT 7 Q __,ti_5 •It Yes.See Sidebar
EW18332 IL REAR
0 N
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
2T3MWRFVXKW039667 United Security ❑Y ®N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
99 9 Martinez Mendez.Gladis. I. ULS1048634-00 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (008) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)!(TELEPHONE) {EMS) (HOSPITAL)
DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 18 9 02,10 /2025 09 00 ®❑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
2 ❑ 18 18
N 3 ❑ 0 CITATIONS ISSUED 0 PENDING / 1 0 PM ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5
z
-a, ARREST NAME / / ❑PM '
o N 1 ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT
30
r 2 ARREST NAME AM
T ! 1 ❑❑PM ❑Unknown work zone type U1
El
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ - ❑AM Workers present? ❑Y 30
547 Homeier.William r 1 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.
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 -<
` ` -' -' 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
0 3. is designed to carry15 or fewer passengers and operated I a contract carrier O
- -----Jr-----
} - } transporting employee � �In the course of their employment(example:employee X
eoennerawvvxv Nat To Scare I transporter-usually a van type vehicle or passenger car):or CO
L L.___a____� �� I I.
4. Is used ordesi natedtotrans rtbetween9and15 passengers,including N
} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or
L L.._-a____. - t i i _ 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires 'D
_ _ placarding(example:placards will be isplayed on the vehicle). m
L 1 . umx L_ / I `_
111hoiAMv :t1
/ iA . — CARRIER NAME Z
ADDRESS 0
1 C
CITY/STATE/ZIP 00
MOTOR CARR.ID 0 Interstate 0 Intrastate
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
----'Y----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
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
11
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Red
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 9 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE