HomeMy WebLinkAbout2025-00010543 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
0110110
III 1100 VI I 100000010000
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X403729415
u, 1 U21 3 4 1 u, 2 U2 2 u, 1 1_12 1 u, 1 U2 1 1 10 u, 4 U2 3 *P0119*
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 El$501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) (83B Injury and/or Tow Due To Crash
El AMENDED
YR 202512025-00010543 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
SUMMIT ST El In 04:34
® ❑ RELATED ®Y 0 N 02 17 2025 ❑AM ❑YES ®NO U1
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION ITT
FT l MI N E S W WAVERLY DR COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR NI SLOW 15 u)
❑ Cook HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUCE 0 uuv 0!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
0 9 /
yr
Kia Motors Co4oul 2016 00-NONE Q 12 DUE TO CRASH ® ❑
13-UNDER CARRIAGE 9 I I! 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 ]$I U2 0 171
M 2 4 SY n 15-OTHER
❑Y ®SNEM DUNK VEH. AT CRASH IN n D 99-UNKNOWN 9 76•TOP 3 *Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, ii_6 I, 4 COM VEH 0 E! 1 0
ELGIN I L 60123 0 1 0 FIRST CONTACT 11 7_: __5 *II Yes.See Sidebar U1
Z DB89740 IL 2025 REAR
TELEPHONE
IL D 0 KN DJ N2A22G7295654 DIRECT AUTO ®Y 0 N U2 m
B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
co
99 9 Same PAIL001120953 1 1—
"6 HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y El 2 c
m �{ DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 iiuv 0 i v ❑DV
/1 9 8 7 Hyundai Tucson 2012 oo-NONE ,i ' t2 DUE TO CRASH 0 2
"iiI 13-UNDER CARRIAGE FIRE ❑ ® U2
c
F 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 9 1,6-TOP 3 X
0 Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN *0istracu n Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s-iI 6 I_i, COM VEH ❑ ® U1 CO
FIRST CONTACT 1 7�' —�_-5 •If Yes.See Sidebar
= ELGIN IL 60120 0 1 0 ZV39253 IL 2025
IL D 0 KM8JUCAC2CU528800 STATE FARM ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
99 9 Same 2327380SFP13 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT( (DOBI (SEX) {SAFT) (AIR) (INJ( 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME(!(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
1 6 05 /
' D
/ / 1 0
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 4 02/17 /2025 04 34 ®pm in a Work Zone? ®N DIRP co
1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 6 n
T
0
2 0 2 18 ( / ❑PM- 0 Construction
Z3 ❑ Ig CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 8
-, 1 ® 11 4 ARREST NAME Menchaca. Emilio 3-707 752693 / / El PM SLMT
ISI CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM• • El Utility
T 2 El ARREST NAME Menchaca. Emilio 6-303-A 752692 021 17 /2025 04 34 ®PM El Unknown work zone type U1 30
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
433-Miracle. Matthew 202 04 ,01 ,2025 10 30 El 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
r — i. combination): r more than pounds(example:truck or truckrtrarler 1. Has a weight rating10 000 i -<
INDICATE NORTH o p3
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
Not To Scale I _ r (example:shuttle or charter bus):or
3. Is designed to carry15 or fewer passengers and operated a contract carrier O
`' A i j y L aumrutaat `
} } } transporting employee in the of their employment(example:employee
_ __
__
_ _ transporter-usually a van type vehicle or passenger car):or X
L L.___a__...; � - 4. Is used or designated to transport between 9 and 15 passengers,including the driver,
C
} } for direct compensation(example:large van used for specific purpose):or
i. i L 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
? 4 placarding(example:placards will be displayed on the vehicle). m
;0
CARRIER NAME Z
ADDRESS 0
r V)
~ CITY/STATE/ZIP g
- i. i. i. i. MOTOR CARR.ID 0 Interstate 0 Intrastate
. . r I ❑ Not in Comm./Govt. 0 Not in Comm./Other
; _Y___-1 USDOT NO. ILCC NO. m
XI
Source of above z
. MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No 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
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
Brown Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 1 TOWED BY/TO.
_Adieu/Impound Lot Garage . 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