HomeMy WebLinkAbout2025-00008977 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100 100011111 0
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003721:32
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INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and f or Tow Due To Crash YR 2025I 2O25-00008977 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m
ADAMS ST Elgin04:47
® ❑ RELATED ®Y 0 N 02 10 2025 ❑AM ❑YES ®NO U1 -<
g PRIVATE mo !day/yr ®PM FLOW CONDITION m
_
FT l MI N E S W WILBER ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR IR SLOW 1 (n
❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Q83 DRIVER O PARKED O DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 1 C)
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FOR DAMAGEDAREA(S) FRO �TOWED U1 1�
NAME(LAST,FIRST,M) Unknown.0. mo Unknown Unknown 00-NONE 11_' Qf T I7.1 DUE TOCRASH ❑
VI E
13-UNDER CARRIAGE ) �:/ FIRE 0
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STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O
SYSTEM IN
9 ❑Y ❑N ❑UNK VEH. ENGAGED 15-OTHER 9 16.TOP 3 DISTRACTED 0 ]$I U2 1 M9 AT CRASH 99-UNKNOWN `Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s_iL 6 �i, COM VEH ❑ j$J 1 0
~ 0 9 0 FIRST CONTACT 1 7_; _5 *uYes.See&debar Ut
REAR
2 Z ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1)
d 99 Ely ❑N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 99 1 I-
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y El 99 0
0 DRIVER X. PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 141Av 0 NCv 0 DV
yr Toyota Corolla 2007 00-NONE 11 12 _1 DUE TO CRASH ❑ ® 1 X/
0 13-UNDER CARRIAGE FIRE 0 ® U2
Ti SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O 2 DISTRACTEDC
a SYSTEM IN 0 ENGAGED 0 15-OTHER O9 16-TOP 3 0 ® SPDR n
❑Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value U1 9 -
POINT OF s I -4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6 i'._ COM VEH ❑ ® CO
F,,, FIRST CONTACT 9 7 _, _5 •If Yes.See Sidebar
9478474 IL 2025 REaR 0 N
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
1 NXBR32E07Z802197 American Family Insurance ❑Y ®N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Nestor.Jaimes 1900-5053-01-50-FPPA BAC
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HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 18 1 02,10 l2025 06 41 ®AM 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 0 20 99
N 1 3 0 0 CITATIONS ISSUED 0 PENDING + ! 0 PM• ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5
z
- u a, ARREST NAME / / ❑PM '
1 21 11 1 0 Utility
0 CITATIONS ISSUED SECTION CITATION NO. ROAD CLEARANCE TIME PENDING SLMT
o AM
t 2 0 ARREST NAME 02 t 10 12025 06 41 ®PM 0 Unknown work zone type U1 25
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ID ❑AM Workers present? D Y 25
1528-Rivera. Kevin 701 - 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 -<
` ` --I -' r INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- } (example:shuttle or charter bus):or
X
- ------I----- - transporting employened to es inthe course passengers5 or fewer thir emplod yment example:employeener X
i jtkialll } } }
transporter-usually a van type vehicle or passenger car):or co
L 4. Is used or designated to transport between 9 and 15 passengers,including N}--- ----; - } } } g Po passen rs,includi the driver,
for direct compensation(example:large van used for specific purpose):or O
L ' ___� unrrrn t i } I 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires a placarding(example:placards will be displayed on the vehicle).
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D
CARRIER NAME Z
__ ADDRESS 'n
V)
Not To scare I Adanteal 0
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
I r ❑ Not in Comm./Govt. 0 Not in Comm./Other
------- --1 - USDOT NO. ILCC NO. rn
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?
❑ Yes II No ElUnknown A
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
Blue
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/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE