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HomeMy WebLinkAbout2025-00008690 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 01101100 IN Ol IIIfft lull DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003723095 u, 1 U2 1 1 1 U, 4 U2 1 U, 1 1_12 U, 1 U2 1 1 9 U1 1 U221 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El$500 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$1,500 ❑NOT ON SCENE(DESK REPORT) (83B Injury and for Tow Due To Crash 0 AMENDED YR 202512025-00008690 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 m 810 MARTIN DR El 04:05 ® ❑ RELATED ❑Y ®N 02 09 2025 ❑AM ❑YES El NO U1 -< _ g PRIVATE mo !day!yr ®PM FLOW CONDITION m COUNTY PROPERTY ❑Y 21 N DOORING ❑y #OF MOTOR ❑SLOW 15 u) ❑ FT l MI N E S W Cook HIT&RUN ❑Y ® N WITH VEHICLESOT, INVLD ❑ STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Qg3 DRIVER O PARKED O DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n 0 6 ! yr 13-UNDER CARRIAGE ©,I O•�. Z FIRE 0 ® E STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED ❑ ]$I U2 m SYSTEM IN ENGAGED 15-OTHER F 2 4 9 9 916-T 3 x ❑Y ❑N ®UNK VEH. AT CRASH 99-UNKNOWN I�e1 `Distraction Value 9 ALGN CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FRIST NTOONTACT 14 7_ItrA1•IO Clfyes.See SidaDar VEH ❑ ) U1 1 0 ... ELGIN IL 60120 0 1 0 DX22381 IL 2025 I TELEPHONE IL D 1C4PJLAB2HW578722 State Farm El ®N U2 19 . m SI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Gonzalez.Areli 1562027-SFP-13 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER 2 XI 0 DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0!My 0 Ncv 0 DV yr Kia Motors Col�orento 2014 00-NONE 11_' 12.._1 DUE TO CRASH 0 2 x 0 13-UNDER CARRIAGE I 2 FIRE 0 El U2 C SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED a SYSTEM IN 9 ENGAGED 9 15-OTHER 016•TOP 3 ❑ ® SPDR n ❑Y ❑N M UNK VEH. AT CRASH 99-UNKNOWN `Oistracton Value O - N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF O I C I. 4 COM VEH ❑ ® tit CO F,,, FIRST CONTACT 9 7 —5 •• •Iryes,See Sidebar C AB63429 I L 2025 I 0 Si) M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 SXYKWDA74EG488459 State Farm ❑V ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 = Martinez. Maria.G. 2633381-SFP-13 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE:ZIP U1 = (UNIT) tSEATI (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 02,09 l2025 04 05 ®pm in a Work Zone? ®N DIRP co I t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 � 2 0 18 1 28 20 ! , ❑PM. ❑Construction 3 * N 3 0 1 8 1 El CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 o 1 ® 11 1 ARREST NAME Vargas. Maritza 11-601 SO475000641 , ! El PM SLMT I$!CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility o N AM 30 t 2 ElARREST NAME Vargas. Maritza 11-708 SO475000642 , , 0 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 30 475-Williarhs. Brianna 201 03 , 11 ,2025 09 00 ❑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 .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 7 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O }} } transporting employees in the course of their employment(example:employee X transporter-usually a van type vehicle or passenger car):or w L L.___a____.lC juiri4. Is used ordesi natedtotrans rtbetween9and15passengers,includingthedriver, } } for direct compensation(examp large van used for speific purose):or 0 L L.._-a-___.I simmer unmet L 1 L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m 1 — lin —— — dike.�-„...my..�—��— placarding(example:placards will be displayed on the vehicle). .,nerd„er - • • . CARRIER NAME Z ADDRESS 0 NOt TO soars ' V) CITY/STATE/ZIP 00 MOTOR CARR.ID 0 Interstate ❑ Intrastate 0 I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other ----------1 - USDOT NO. ILCC NO. m XI Source of above z . Form Number m Xl IDOT PERMIT NO. WIDELOAD'; 0 Yes 0 No 2 TRAILER VIM 1 m co LOCAL USE ONLY TRAILER VIN 2 m v 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 Gray u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. _Adieu/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 DUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE