HomeMy WebLinkAbout2025-00010438 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100
DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X003727345
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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 1215501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00010438 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
GALVIN DR Elgin 05:57
® ❑ RELATED ❑Y ®N 02 17 2025 ®AM ❑YES ®NO U1
g PRIVATE mo !day!yr ❑PM FLOW CONDITION m
12 !MI N E S W Northwest Pk COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 Co
® ® Kane 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
183 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
FOR DAMAGEDAREA(S) FRONT TOWED U1 0
Tre o.John. M. 0 1 /
yr 13-UNDER CARRIAGE 1a.I 2 ' 2 FIRE 0 ® <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 14 U2 m
M 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 _
❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8_iL 6 4 COM VEH 0 ZgJ 1 O
. ~ Hampshire IL 60140 0 1 0 FIRST CONTACT 12 7_; -5 *u yes.See Sidebar U1
Z P DN18578 IL 2025 E
TELEPHONE
IL D 1 G 1 PC5SH2B7202797 Allstate ❑Y igi N U2 I—
IL'i n EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 802497808 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF`Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ❑ N 3 2 c
p; DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 ivy 0 Ncv ❑Dv
!1 9 6 8 Toyota RAV4 2024 00-NONE 11"j t2--_, DUE TO CRASH ❑ 2 x
o 13-UNDERCARRIAGE ta;l 2 FIRE ❑ ® U2 C
F 2 4 ❑Y El
IN ENGAGED 15-OTHER 9 16•TOP
3 3 X
❑N UNK VEH. AT CRASH 99-UNKNOWN *Oistrac on Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 iI- 6 �' 4 COM VEH 0 ® U1 CO
_
FIRST CONTACT 6 Y__{_-
•If Yes.See Sidebar C— Kingston IL 60145 0 1 0 ER78974 IL 2025 REAR 0 Si)
Z D
IL D 2T3A1 RFVXRW459294 Progressive ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 X
Same 95979331 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND❑N 2 U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 2 21 (71 l025 05 57 ®❑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
o"
2 28 11 ( ( ❑PM, ❑Construction *
1
Z3 0 1!>I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5
a1 ® 11 1 ARREST NAME Trejo,John. M. 11-601 298001197W / ! El PM SLMT
o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
r 2 ARREST NAME AM
7 ( 1 ❑❑pM ❑Unknown work zone type U1
El
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 30
298-Lopez, Mirko 901 272-Bajak ( / ❑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 r --1 -' r INDICATE NORTH combination):or —I
=N D BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} - } r r r (example:shuttle or charter bus):or 0
`""A""' JOJ Not To Scale I. } } transportlg emoloyees1iin5 thecourser�o tthe,ers�antloperatedemployment ampleontract carrier I 0
?u - - - - -- transporterg-usually a van type vehicle or passenger car):orco
4. Is used or designated to transport between 9 and 15 passengers,including rCjt
�- } } •
for direct compensation(example:large van used for cific ur mdudi the driver,
o Pe ( P 9 Pe purpose):or O
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L L____a____. _ i i L 5. Is anyvehicle used to transport anyhazardous material(HAZMAT)that requires
(r R7 o i_ .___ ) placardig(example:placards will be isplayed on the vehicle). X)
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Unh2 Until - . 1
CARRIER NAME Z
ADDRESS 0
T.
. . -.- . __.-1
T . . . . _
CITY/STATE/ZIPC)
MOTOR CARR.ID 0 Interstate 0 Intrastate
I r ❑ Not in Comm./Govt. 0 Not in Comm./Other
; _Y_ __.; USDOT NO. ILCC NO. m
XI
Source of above z
. Was a driver/vehicle Examination Report Form completed? r
HAZMAT ❑Yes 0 No ❑Unknown Out of Service ❑Yes ❑No :
MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No C
Z
Form Number 0
m
Xl
IDOT PERMIT NO. WIDELOAD'; 0 Yes 0 No 2
TRAILER VIN 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
0
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
Blue,Dark White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ElNOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE