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HomeMy WebLinkAbout2025-00014845 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I01101100 I011010100 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XO03748973 u, 1 U21 1 1 2 U1 2 U2 1 U, 1 U2 9 U, 1 U2 1 1 10 U1 3 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash ❑AMENDED YR 2025I 2025-00014845 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1 DUNDEE AVE El In 03:45 ® ❑ RELATED ®Y 0 N 03 07 2025 12,— ❑YES ®NO U1 -Cot g PRIVATE mo /day/yr ®PM FLOW CONDITION MFT!MI N E S W LUDLOW AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 15 0) ❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 —I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0 Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEON. 0 EWES ❑uuv 0!Cy ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0 FROM TOWED U1 0 NAME(LAST,FIRST,M) Ortiz.Jose. M. mo Chrysler 300 2019 00-NONE ©,: Oil DUE TO CRASH ® ❑ 13-UNDER CARRIAGE } FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O 2 DISTRACTED 0THER ]$I U2 4 <<Tl M 2 5 SYTM❑Y ®SNE❑UNK VEH. 0 ATCRASHD 0 15-99-UUNKNOWN 916•TOP3 `DistractionValue ALGN X. r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ iI 6 4 COM VEH 0 j$J 1 0 ~ SchaumburgI L 60194 0 1 0 FIRST CONTACT 12 7 ;1 _5 *lIYes.See Sidebar U1 Z ES18166 IL 2025 Ismi TELEPHONE IL D 0 2C3CCARG8KH602481 American Family Ins ❑Y IlN U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Borrayo. Ingrid 41106-08336-52 2 r o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER D Refused El El 2 c m x DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑ uv 0 NCv ❑Dv /1 9 8 0 Chevrolet Traverse 2020' 00-NONE 11 ` �1.-_, DUE TO CRASH ❑ 2 xj 0 13-UNDER CARRIAGE 1, FIRE ❑ ® U2 C c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER O9 16-TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraglon Value 0 POINT OF s I 4 COM VEH D ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 5 1:._ C FIRST CONTACT 11 7 _,r_5 C. If Yes.See Sidebar Z Chicago IL 60630 0 1 0 DH24589 IL 2025 I 0 Si) Z IL D 0 1 G N ERG KW1 LJ 164353 Kemper ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Varela.Antonia 12RA000053504 BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP 996 < Refused RESPONDER U1 = )UNIT) ISEATI (DORI (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 1 4 11 / / / UI 3 D:A / / 1 0 EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 4 03,07 /2025 03 46 ®AM in a Work Zone? ®N DIRP co 1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 ✓ 2 ❑ 2 99 03,07 ,2025 04 17 ®PM ❑Construction >F <w 1 O ❑ ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 3 ❑AM ❑Maintenance U2 -a, ARREST NAME Ortiz.Jose. M. 11-902 495000441 03/07/2025 04 25 Igi pM SLMT 0CITATIONS ISSUED PENDING® 1 1 4Utility o N I SECTION CITATION NO. ROAD CLEARANCE TIME 0 t 2 El ARREST NAME 03/07 /2025 04 42 ®PM ❑Unknown work zone type 0 AM U1 30 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME CI AM Workers present? ❑Y 30 495-Sjodir.Jacob 201 272-Bajak 04 , 15/2025 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 . 0 ADDITIONAL UNITS FORMS. r -- r••--, A CMV is defined as any motor vehicle used to transport passengers or property and: Z 1. Has a weght rating more than 10,000 pounds(example:truck or truck/trailer -< ' }--__r-_--; } combination):or INDICATE NORTH BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver n 8 I I - (example:shuttle or charter bus):or X I { I 3. Is designed to carry15 or fewer passengers and operated a contract carrier O -- > - } } } transporting employee in the course of their employment(example:employee X Ludiow?Avenue transporter-usually a van type vehicle or passenger car):or CO _ 1 } } } 4. Is used or designated to transport between 9 and 15 passengers,including the driver. N ,. — — — — for direct compensation(example:large van used for specific purpose):or O L L____a____. Unll?1'? _ t i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires III my —� placarding(example:placards will be displayed on the vehicle). ,Zmt 9 CARRIER NAME Z klnit?z —I ADDRESS n I I I. CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate ElIntrastate I I T I I I ❑ Not in Comm./Govt. Not in Comm./Other I I Not To Scale I USDOT NO. ILCC NO. m XI Source of above z . ❑ Yes 0 No 0 Unknown g 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 Gray Gray 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