HomeMy WebLinkAbout2025-00014314 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT) El B Injury and f or Tow Due To Crash
El AMENDED YR 202512025-00014314 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r7
® ❑ RELATED ❑Y ®N 03 05 2025 ®AM El YES ®No U1 -<
HIGGINS RD Elgin 08:31
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION ITT
0 !MI N E S W Spectrum Dr COUNTY PROPERTY 0 Y ® N DOORING ❑Y #OF MOTOR ❑SLOW 1 (n
® p Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ® STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS O
tg:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 ED,ES 0 NW 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0
0 5 /
yr Q -
13-UNDER CARRIAGE 1a i 2 FIRE 0 NI E
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 Ea U2 4 (<Tl
F 2 4 SYTM❑Y ®S NE DUNK VEH. 0 AT CRASH 0 99-UNK 15- NOWN THER9 76•TOP 3 *Distraction Value 9 ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ iI 6 4 COM VEH 0 Ea 1 0
" �- GILBERTS I L 60136 0 1 0 FIRST CONTACT 12 7 ; _5 *9Yes.See Sidebar U1
ZBR90904 IL 2025 E
TELEPHONE
IL D 0 1 HGCM665X5A038524 Farmers Insurance ❑Y ®N U2 m
.5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 De La Cruz. Luisito A7998541210 2 r
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 2 c
m N DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED 0 PEOAL ❑EWES 0
1 9 6 9 Cadillac XT5 2017 oo-NONE ,t"i 12..-_, DUETO CRASH rg ❑ 2
.. Yr 13-UNDERCARRIAGE ta;l 2 FIRE ❑ ® U2 C
c
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X
❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraclion Value 9 g
POINT OF s II 4 COM VEH 0 ® Ut CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR - MI'._
FIRST CONTACT 6 Y :j_ ._5 •)ryes.See SidebarC
Z GILBERTS IL 60136 0 1 0 CQ83237 IL 2025 iaR 0
Z
IL D 0 1 GYKN BRS5HZ165649 State Farm ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire 99 9 Same J32 2245-C30-13A SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Sherman RESPONDER u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),(A.DDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
2 4 07 /
2 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
u 1 ® 11 1 03,05 ,2025 08 31 ®❑AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1 C)
v 2 ❑ 28 03 03,05 ,2025 08 34 0 pM ❑Construction
R 3 0 ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
z J ®AM ❑Maintenance U2
a1 ® 11 1 ARREST NAME De la Cruz.Veronica.S. 11-601-Ax 1538000179 03,05/2025 08 41 ❑pM SLMT
S' N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
AM u, 55
r 2 El ARREST NAME 03/05 i2025 09 07 [M PM El Unknown work zone type
2 2 3 0 OFFICER ID SIGNATURE BEAT I DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 55
1538-Estrada. Leticia 900 04 ,01 ,2025 01 30 ®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 e---•r••--, , - ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
GelvE"?Rd Not To Scale J 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
j I INDICATE NORTH p0
BY ARROW combination):or
2 Is used or designed to transport more than 15 passengers including the driver
i ® - } (example:shuttle or charter bus):or
X
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 w
L I.___a____J - - - - 4. Is used ordesi natedtotrans rtbetween9and15passengers,indudingthedrrver,
C
$ } } for direct compensation(example:large van used for speific purose):or 0
L L____a____. — —Unita •.2 _ t i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
1 j0) placarding(example:placards will be displayed on the vehicle). XI
D
me?Ftd - CARRIER NAME Z
r r -1- 1 II i---
__ ADDRESS
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0
Y+eo+aon..Nu CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
-"--------1 - USDOT NO. ILCC NO. rn
XI
Source of above z
. 0 Yes 0 No ❑ Unknown 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
v
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
Black White
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: 1 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG.—CARGO BODY TYPE_LOAD TYPE