HomeMy WebLinkAbout2025-00013882 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
El AMENDED ElB Injury and/or Tow Due To Crash YR 202512025-00013882 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED ®Y 0 N 03 03 2025 ❑AM ❑YES ®No u1 -<
MAROON DR Elgin03:13
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FTlMI N E S W DOVER DR COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ Cook HIT&RUN ❑V ® N WITH VEHICLESOT,
INVLD DO
U2 --I
El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Qg3 DRIVER O PARKED O DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
FOR DAMAGEDAREA(S) FROf�tr TOWED U1 O
Olsson.Gary.A. 0 5
yr 13-UNDERCARRIAGE 10, !!. 2 FIRE 0 IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
M 2 SYTM IN ENGAGETHER
4 ❑Y ®SNE❑UNK VEH. 0 AT CRASH 0 99-U15-UNKNOWN 9 le-TOP 3 ,Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ it S jl COM VEH 0 Ea 1 0
~ ELGIN I N I L 60120 0 1 0 FIRST CONTACT 4 7_• -_5 *II Yes.See Sidebar Ut
Z100793SB IL 2025 Ismi
TELEPHONE
IL Other 7 4DRBUC8NXGB165112 Alliant ❑Y ®N U2 1-
Ill13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
99 9 U46 School District P4-1001458-2425-01 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET.CITY.STATE,ZIP PHONE NUMBER
RESPONDER
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p DRIVER X. PARKED 0 DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 NM,ly 0 Ncv 0 DV
!1 9 yf 5 Kia Motors Co�ptima 2015 00-NONE QI 12 . 2 DUE TO CRASH 0 ® U2 2 C
omo _ 13-UNDER CARRIAGE
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F 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 X
0 Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN •Oistraglon 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 11 7� _5 •(ryes.See SidebarC
H ELGIN IL 60120 0 1 0 CY60608 IL 2025 RE 0 Si)
M
IL D 0 5XXGM4A79FG444135 StateFarm ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
99 9 Zenon Lopez. Lemuel 1617454-SFP-14 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE:ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
0 O
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
u 1 ® 18 1 03,03 r2025 03 13 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
0 2 04 99 ) ) 0 PM ❑Construction *
Z 3 0 Igi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
E)AM ❑Maintenance U2
-a, ARREST NAME Olsson.Gary.A. 11-601-Ax (w)455-417 / r El PM
1 ® 11 1 0CITATIONS ISSUED SECTION CITATION NO. ROAD CLEARANCE TIME PENDING • Utilit SLMT
o NEly
r 2 0 ARREST NAME 03 i 03 r2025 03 13 ®PM ElUnknown work zone type U1 25
n T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 - ❑AM Workers present? ❑Y 25
455 Halla�.Gabriel 302 , ❑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- }-- --I-- --; urar Niroen7ar. - INDICATE NORTH combination):or .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
/mmok _ (example:shuttle or charter bus):or 0
L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
} } } transporting employees in the course of their employment(example:employee X
` transporter-usually a van type vehicle or passenger car):or co
L L.___a____� ` 4. Is used ordesi natedtotrans rtbetween9and15 ge ng N
} } for direct com nation exam I lar a van used for s �cifice ur o ):or [he driver,
• Pe ( P 9 Pe p pose):or 0
L t i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D
Nplacarding(example:placards will be displayed on the vehicle). XI
!L-! - -- . 1
CARRIER NAME Z
riroz - -- O
ADDRESS
V)
Not To Scale CITY/STATE/ZIP n
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other
-"--------1 - USDOT NO. ILCC NO. rn
XI
Source of above 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
v
TRAILER WIDTH(S) 0-96" 97-102" >102' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Yellow Red
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 0 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE