HomeMy WebLinkAbout2025-00011211 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets _ 01111101111
I01101100
lflfl 1110 fli 10
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00373469
u, 9 u21 3 4 1 U116 U2 1 U199 1_12 1 U,99 U2 1 1 10 u, 3 U211 *P 0119*
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 1215501-51.500 ®ON SCENE 1
VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED YR 202512025-00011211 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 -n
® ❑ RELATED ®Y 0 N 02 20 2025 ®AM ❑YES ®NO U1
S STATE ST Elgin 08:22
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION Ill
FT!MI N E S W RT20 EB COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 5 (A
❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD ❑ STOPPED U2 --I
CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
/ / FOR DAMAGEDAREA(S) FRO T TOWED U1 Q
Unknown.O. Unknown Unknown 00-NONE „ 12 , DUE TOCRASH ❑ VI
NAME(LAST,FIRST.M) mo yr 13-UNDER CARRIAGE 101 ! 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ rvi U2 2 111
SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3Id
9 9 ❑Y ❑N ❑UNK VEH. AT CRASH ®-UNKNOWN `Distraction value ALGN =
a 4
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _,'�a �i,_ COM VEH ❑ Ea
99 1
I- 0 9 FIRST CONTACT 7 ; _5 *IIYes.SeeSidebar U1 0
REAR
2 Z ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 11/
UNKNOWN ❑Y ❑N U2 I'
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same UNKNOWN 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF`Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
.',3RESPOND 0 N 0
m
g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES 0
/1 9 6 3 El Dorado MfgEArtder 2007 oo-NONE 0t2 -_, DUE TO CRASH ❑ MI 33 x
�^ NAME(LAST,FIRST,M) ELIZONDO. LETICIA
o 13-UNDER CARRIAGE 10 I 2 FIRE ❑ ® U2 C
ij
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistraclion Value 0
i1I
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 5 4 COM VEH D ®
FIRST CONTACT 11 8 7 _, _5 •
— Hanover Park IL 60133 0 1 0 M172655 IL 0 I If Yes.See Sidebar U1 W
0 N
Z
IL B 7 1 N9MNAC637C084087 PACE ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
PACE SUBURBAN BUS DI PACE BAc E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB' (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
2 7 08 /
LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur IN Y
N 1 ® 11 1 02/20 /2025 08 22 ®❑pM in a Work Zone? 0 N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 2
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 0 20 99
N 3 0 0 CITATIONS ISSUED 0 PENDING • + / ❑PM• ®Construction >F
SECTION CITATION NO. EMS ARRIVED TIME ❑AM El Maintenance U2 5
z
-a, ARREST NAME / / El PM '
o N ® 11 `7 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ,..,Utility SLMT
30
t 2 ARREST NAME AM
7 / / ❑❑PM 0 Unknown work zone type U1
El
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
❑Y 30
244-Blomberg. Michael 701 275-Engelke / / ❑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 -<
c ` --I -' r INDICATE NORTH combination):or —I
73
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-----; i
trans tl Rig em lloyeeo slin the course of 5 or fewer rye r emplors andyment example:employee a contract der} } } ng pAVans rter-usually a van Type vehicle or passen r car):or 03
` `-___a N Not ] 4. Is used ordesinatedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or 0
L L____a____.I i t i i Y 5. Is any vehicle used to transport an hazardous material(HAZMAT)that requires III
J placarding(example:placards will be displayed on the vehicle) XI
CARRIER NAME Z
EABTBOIM'ML420/De7117AMP _ __ ADDRESS
C)
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate El Intrastate
I r ❑ Not in Comm./Govt. 0 Not in Comm./Other
-----------1 - USDOT NO. ILCC NO. rn
XI
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
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes 0 No 0 Unknown M
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
0
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: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE