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HomeMy WebLinkAbout2025-00012651 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I01101100 lflfl 110 11100 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003737636 u, 1 U21 2 4 1 U, 2 U2 1 U, 1 1_12 1 U,99 U216 1 15 U1 1 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW ' Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) El B Injury and/or Tow Due To Crash El AMENDED YR 202512025-00012651 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn ® ❑ RELATED ®Y 0 N 02 26 2025 ®AM ❑YES ®NO U1 -< N CRYSTAL AVE Elgin 10:13 g PRIVATE mo /day/yr ❑PM FLOW CONDITION IT1 FT N E S W LAWRENCEAVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR El SLOW 1 (n ❑ Kane HIT ❑Y ® N WITH VEHICLES INVLD El STOPPED U2 --I ® &RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0 QT3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0 0 7 / yr 13-UNDER CARRIAGE © al ,I !�. 2 FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 0 171 M 2 SY 15-OTHER 5 ❑Y ®SNE❑UNK VEH. O AT CRASM IN H O 99-UNKNOWN 9 16•TOP 3 `Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�a Ii.4 COM VEH 0 Ea 3 0 ELGIN IL 60120 0 1 0 FIRST CONTACT 11 7_; __5 *II Yes.See Sidebar U1 Z FD11345 IL 2026 . E TELEPHONE IL D J H MCM56353C060762 Kemper ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same 12RA000037804 2 r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y El 2 0 m g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0 i v 0 DV /2 0 0 3 Infiniti G35 2005 00-NONE 0. QI'-O DUE TO CRASH rg ❑ 2 x 0 13-UNDER CARRIAGE 10( I 2 FIRE El El U2 C M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istraellon Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S-il 6 I1:, 4 COM VEH ❑ ® U1 W FIRST CONTACT 12 7 .5 •If Yes.See Sidebar z ELGIN IL 60123 0 1 0 EZ12048 IL 2025 I 9 N IL D JNKCV54E25M416602 American Alliance ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Menez.Cristina.A. ILAA095933300 BAC $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS),(TELEPHONEI (EMS) (HOSPITAL) 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 11 1 21 /61 /025 10 14 ®❑PM in a Work Zone? ®N DIRP co 1 t PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 5 C) T o" 2 0 2 99 / / ❑PM• ❑Construction X 7 Z 3 0 1!>I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 a ® 11 1 ARREST NAME Delgado. Luis.G. 11-901-A 327003099 / / ❑PM SLMT o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility r 2 ❑ ARREST NAME El AM T , / pM El Unknown work zone type 30 U1 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30 327-Hromadka.Scott 601 368-Davenport 31 , 51 /025 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 truck trailer -< i- ----_r_-_-; INDICATE NORTH combination):or p3 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C 4-N— - (example:shuttle or charter bus):or 0 3. Is designed to I- --I-- ij LI t carry15 or fewer passengers and operated a contract carrier 0 - - -- } } } transporting employee �In the course of their employment(example:employee transporter-usually a van type vehicle or passenger car):or w L 4. Is used or designated to transport between 9 and 15 passengers,including C }--- ----; - - } } } 9 Po passen rs,indudi the driver, B7CnWnAw. for direct compensation(example:large van used for specific purpose):or t i t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires -rwn r Pc 9 • placarding(example:placards will be displayed on the vehicle). XI - CARRIER NAME Z ADDRESS T. Not To Scale j CITY/STATE/ZIP n MOTOR CARR.ID 0 Interstate 0 Intrastate 1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other --- --1 - USDOT NO. ILCC NO. m XI Source of above z . -I Were HAZMAT placards on vehicle? 0 Yes 0 No = If Yes,Name on placard O 4 digit UN NO. 1 digit Hazard class No. Xl Xl 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 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 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 Silver Black u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. 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