HomeMy WebLinkAbout2025-00005473 ILLINOIS TRAFFIC CRASH REPORT sheet 1 Of 2 Sheets 1111111111111111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
0 AMENDED YR 202512025-00005473 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
N MCLEAN BLVD EIin09:00
® ❑ RELATED ®Y 0 N 01 25 2025 DAM ❑YES ®NO U1 -<
_ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT l MI N E S W BIG TIMBER RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 15 u)
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!Cy 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
FOR DAMAGEDAREA(S) FROf'tf�TOWED U1 Q
Villa Cortez.Jose. L. 1 1 /
yr 13-UNDER CARRIAGE } FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O 2 DISTRACTED 0 ]$I U2 0 m
M I 2 4 15-OTHER
❑Y ®N
SYSTEM
❑UNK VEH. 0 AT CRASH D 0 99-UNKNOWN 9 76•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $_iL 6 I,--.4 COM VEH 0 0 1 O
ZE LG I N I L 60123 0 1 0 DT36160 I L FIRST CONTACT 12 Y ; __s *Ir ves.See Sidebar Ut
TELEPHONE
IL D 1 FADP3F28EL395743 Kemper ❑Y ®N U2 93 . m
2. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 12RA000010960 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ❑ N 2 eu
m x DRIVER ❑ PARKED ❑DRIVERLESS ❑ FED ❑PEDAL 0 EWES 0!My 0 Ncv 0 DV
2 0 0 0 Ford Edge 2012 00-NONE „ "•
�i,O DUE TO CRASH ❑ 2
0 13-UNDER CARRIAGE I, FIRE ID ® U2
c ®
M 2 5 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X
❑Y El N ❑UNK VEH. AT CRASH 99-UNKNOWN `0istracton Value 9 U1 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�!-4 COM VEH ❑ ® W
H FIRST CONTACT 11 Y �_r_s C.
If Yes,See Sidebar C
Machesney Park IL 61115 0 1 0 DK94480 IL I 0 Si)
Z
IL D 2FMDK4AK9CBA32883 American Freedom ❑Y 123 N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
Moreno.Shawn. L. 12-2387874-01 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
ui =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
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71
/ U1 1 D
1 0
E/ MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 4 01 ,25 ,2025 09 00 0 AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
O 2 ❑ 25 28 , , 0 PM ❑Construction >E
" 3 ❑ I!!I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
o 1 ® 11 4 ARREST NAME Villa Cortez.Jose. L. 11-306 487000512 , r El PM SLMT
I$!CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME N El AM• El Utility
o t 2 El ARREST NAME Villa Cortez.Jose. L. 11-601-Ax W487000513 01 r 25 i2025 09 35 ®PM ❑Unknown work zone type U1 30
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 30
487-Heal. Kayla 501 03 ,04,2025 01 30 ®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----r-•--, A CMV is defined as any motor vehicle used to transport passengers or property and: Z
. 0
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
r r --I- -' I I r INDICATE NORTH combination):or -I
N?McLean?Blvd ; BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver and:
® Ii. e. r r (example:shuttle or charter bus):or 0
< <---- -•-•; I I I / . transporting mployeened to slin the course passengers5 or fewer thir emplod yment example:employee
transporter} I- I-
L L.___a-_--; O\. . sed or d si nated to transport between 9 and 15 passengers,including the driver,
No
CO
' Q, Big?Trmber?Rd ; } } }
•
for direct compensation(example:large van used for speific purose):or
J
. — —
71
L--_-a-___-I - i 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
rn
— _ placarding(example:placards will be displayed on the vehicle). XI
. 1
- — CARRIER NAME Z
Ar r f ''. , „- , 1. L. 1.. ADDRESS D
C)
CITY/STATE/ZIP
Not To Scale MOTOR CARR.ID 0 Interstate ElIntrastate
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--- ❑ Not in Comm./Govt. Not in Comm./Other0
:- . -- - --1 L L USDOT NO. ILCC NO.
<
I m
Source of above z
. xi
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z
own tank)? 0 Yes 0 No 0 Unknown
T.
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
to
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
Black White
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BYITO.
Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE—