HomeMy WebLinkAbout2025-00008810 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
I01101100 VI 11100111100
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003721a19'
u, 1 u21 1 1 1 u1 4 U2 1 U111 u2 1 U1 1 U2 1 1 9 U1 17 U222 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY El$500 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 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 202512025-00008810 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rl
® ❑ RELATED ❑Y ®N 02 10 2025 ®AM ❑YES ®NO U1 -<
ROUTE 20 HWY Elgin 07:40
g PRIVATE mo /day/yr ❑PM FLOW CONDITION ITI
10 /MI N E s w Lon common Pk COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 C/)
® g Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
tg:DRIVER p PARKED El DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
O 2 /
Cadillac XTS 2017 00-NONE 11 Oi_, DUE TO CRASH ® ❑ E
13-UNDER CARRIAGE 1a , 2 FIRE ❑ al
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® ❑ U2 0 M
M 2 4 Y SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 6 ALGN =
❑ ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $,_iL 6 I,.4 COM VEH 0 0 1 0
~ ELGIN N I L 60123 0 1 0 FIRST CONTACT 12 7 ; _5 *Irves.See Sidebar Ut
Z EL73063 IL 2025 REAR
TELEPHONE
IL D 2G61 M5S30H9125520 Progressive ❑v ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 978959712 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ❑ N 3 2 eu
0 DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 Nuy 0 i v 0 DV
/1 9 8 6 Acura TL 2006 00-NONE 1t"i 12'.-_, DUE TO CRASH ❑ 1
0 13-UNDER CARRIAGE 10 1 2 FIRE ❑ ® U2 C
c
M 1 3 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 3 X
❑N DUNK VEH. AT CRASH 99-UNKNOWN *Distraction Value
POINT OF 8 i 4 COM VEH D ® Ut W
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR -II 5 1'
FIRST CONTACT 6 Y__{_O ._5 •If Yes,See Sidebar
= Lombard IL 60148 B 2 1 AE76018 IL 2024 REAR 0 N
�
IL D 19UUA66256A057048 State Farm ❑Y ®N RDEF73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Johnson.Joshua, P. 1592412SFP13 BAc $
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)((A.DDRESS))(TELEPHONE! (EMS) (HOSPITAL)
2 3 04 /
U1 1 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 ® 18 5 02,10 /2025 07 40 ®❑PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
O 2 0 28 40 + ) ❑PM ❑Construction >F
1 4
Z 3 0 1!>I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM 0 Maintenance U2
o1 ® 11 5 ARREST NAME Metallo, Luciano 11-601 298001193W r r ❑PM SLMT
o N
❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility
50
T 2 0 ARREST NAME AM
1 r ❑❑PM 0 Unknown work zone type ul
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ID ❑AM Workers present? ❑Y 50
298-Lopez, Mirko 801 - r r ❑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 -<
c ` -' -' `' r INDICATE NORTH combination):or —I
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
a N— •_N 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O
-- -- - I. } } transporting employees in the course of their employment(example:employee I °
Not re d transporter-usually a van type vehicle or passenger car):or w
L = • 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y I. } . for direct compensation(example::large van used for speific purpoe):o
i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)thatrequiresrrve r
O
D
placarding(example:placards will be displayed on the vehicle). XI
. 1
CARRIER NAME Z
ADDRESS 0
V)
C)
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. ❑ Not in Comm./Other 00
'----;'----1 Laapcanman7Pray. - E USDOT NO. ILCC NO. m
XI
Source of above z
. Form Number m
Xl
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
w
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 0 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Black Blue
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
Redmons/Owners Residence . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE