HomeMy WebLinkAbout2025-00014135 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
M01101100
111 I II 1111100
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XCO3744d,9
u, 1 U21 1 1 8 U1 7 U2 1 U, 1 1_12 1 U, 1 U2 1 1 11 U1 1 U211 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S 0$501-$1.500 ®ON SCENE 3
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
0 AMENDED YR 202512025-00014135 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I
® ❑ RELATED ®Y 0 N 03 04 2025 ®AM ❑YES ®NO U1 -<
N RANDALL RD Elgin10:46
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FTlMI N E S W FLETCHER DR COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 Cn
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD DO
U2 —I
lgi 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 MUSS 0 NIA/ 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 n
FROhrr TOWED EN
U1 0NAME(LAST,FIRST,M) Villarreal. Nicholas. E. mo Ford Edge 2017 00-NONE 11 OI_, ODE TO CRASH ❑
13-UNDER CARRIAGE 10 : 2 FIRE 0
3 <<
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 T1
M 2 4 ❑Y ®SNE❑ 15-OTHER
UNK VEH. 0 ATCRASHD 0 99-UNKNOWN 9 76•TOP 3 `Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s_:iL B 4 COM VEH 0 Ea 1 0
F- FIRST CONTACT 12 7_ —, _5 *IIYes.See Sidebar U1
Z SOUTH ELGIN IL 60177 0 1 0 BB59393 IL 2025 REAR
TELEPHONE
IL D 2FM PK3J91 H BC16775 All State ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
Villarreal. Marisa.A. 974935537 2 r
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 X
p; DRIVER ❑ PARKED 0 DRIVERLESS ❑ FED ❑PEDAL 0 EWES ❑Nuv 0 NCv ❑Dv CIRCLE NUMBER(S) U1
� !1 9 yf 9 Hyundai Santa Fe 2017 00-NONE 11_"1 Qi.O DUE TO CRASH 0 ❑ 2 x
0 13-UNDER CARRIAGE 10 i I. E FIRE ❑ ® U2 C
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F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distrac on Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s iII _4 COM VEH D ® U1 CO
FIRST CONTACT 6 Y :j=SaR _5 •(ryes,See Sidebar C
H ELGIN Z IL 60123 0 1 0 AR27841 IL
0 Si)
M
IL D SXYZTDLB9HG439478 Progressive ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 976339149 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER
U1 =
(UNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
E/ MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 1 03,04 l2025 10 46 ®❑pM in a Work Zone? ®N DIRP co
1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
0 2 03 99 , , ❑PM ❑Construction *
R 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
oER 11 1 ARREST NAME Villarreal. Nicholas. E. 11-710-A 1545-212 / ! ❑PM SLMT
o 45
N 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
r 2 ❑ 11 1 ARREST NAME AM
T 1 r ❑❑PM ❑Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ ❑AM Workers present? ❑Y 45
1545-VanEycke. Brier 502 331-Ziegler , / ❑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
0 ; ADDITIONAL UNITS FORMS.
r ----r••--, , A CMV is defined as any motor vehicle used to transport passengers or property and: Z
i- �___-r____; I _ 1. Hasa weight
ign):ht rating more than 10,000 pounds( xamp :truck or truck/trailer e le -<
INDICATE NORTH
—I
Not To Scale J BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
I - (example:shuttle or charter bus):or n
' r r r °
I 3. Is designed to carry15 or fewer passengers and operated a contract carrier O
- I. } } transporting employee In the courses of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or w
C
L L.___a____� NIMI ll - I. •4. Is used ordesi natedtotrans rtbetween9and15passengers,includingthedriver,
I I I } } } for direct compensation(exam :large van used for speific purose):or
L--_-a-___-I - l. l. I I 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle).
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111-0.1.1#2 CARRIER NAME Z
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CITY/STATE/ZIP g
l�r MOTOR CARR.ID 0 Interstate ❑ Intrastate
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V
USDOT NO. ILCC NO. m
XI
Source of above z
. Form Number
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Xl
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
a
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
Gray Orange
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 1 TOWED BY/TO.
SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Other/Unknown VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE