HomeMy WebLinkAbout2025-00016143 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑5501-51.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
0 AMENDED YR 2025I 2025-00016143 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
715 STEWART AVE Elgin09:53
® ❑ RELATED ❑Y ®N 03 12 2025 ❑AM ❑YES ®NO U1 -<
_ PRIVATE mo /day/yr ®PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 2 fA
❑ FT l MI N E S W Cook HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER O PARKED El DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 NOV 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
0 1
yr Impala1t. 12 Q
13-UNDER CARRIAGE VI
FIRE 0IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED 0 0U2 2 m
M 2 4 ❑Y ONEM❑UNK VEH. O AT CRASH IN ENGAGEO 99-UUNKNOWN 9 76-TOPO ,Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6, it 6 it°COM VEH 0 0 1 C)
~ ELGIN IL 60123 0 1 0 FIRST CONTACT 1 7 '1 _O =I(Yea.See Sidebar U1 0
ZEC69442 IL 2025 iisui
TELEPHONE
IL D 0 2G1165S37F9288436 American Alliance Insuran ❑Y ISI N U2 m
5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same ILAA099099800 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y ❑ N 2 0
0 DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NI/v 0 NOV 0 Dv CIRCLE NUMBER(S) U1
yr Dodge Ram 3500(pickup) 2020 00-NONE ,(` t2 "_, DUE TO CRASH ❑ 1
Ja 13-UNDER CARRIAGE 6I 2 FIRE 0 El U2 C
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 ® SPDR 0
a SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3
0 Y NJN 0 UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value O
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF ` COM VEH ❑ ® Ut CO
1.* FIRST CONTACT 7 O7 6 L.5 •If Yes.See Sidebar
2975428B IL 2025 REAR 0
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
3C63RRJL8LG254577 State Farm Insurance ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Garcia.Joshua. R. 3449115SFP13 BAc $
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)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
0 O
E/ MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 18 1 03,12 i2025 10 00 ®AM in a Work Zone? ®N DIRP co
I 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)
2 0 28 15 / / 0 PM 0 Construction *
01
4
R 3 0 1!>I CITATIONS ISSUED El PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM ❑Maintenance U2
aD ® 11 1 ARREST NAME Pasillas Pasillas.Juan.Y. 11-601 W469002302 / ! El PM SLMT
o N
❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' 0 Utility
0 AM
t 2 0 ARREST NAME 03l 12 r2025 10 00 0 PM El Unknown work zone type U1 3O
n T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 - ❑AM Workers present? ❑Y 30
469-Taylor,Jonathan 201 r r ❑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
Not To Scale j 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
i- }--__r-_--; - INDICATE NORTH combination):or
p0
0 i BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ } (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
a transporter-usually a van type vehicle or passenger car):or w
L 4. Is used or designated to transport between 9 and 15 passengers,includingC
a.
}-'' ----; a �15?Sm�nart - } } g po p :orthe dryer,
,,,i 1 Avenue for direct compensation(example:large van used for specific purpose):or
L L____a____. j t i. i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
i r placarding(example:placards will be displayed on the vehicle). ,Zt
D
CARRIER NAME Z
ADDRESS 0
w
C)
CITY/STATE/ZIP g
_ MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I k ❑ Not in Comm./Govt. 0 Not in Comm./Other
0
L i C USDOT NO. ILCC NO. C
XI
Source of above z
. • m
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 M
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 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
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.
_Other/Unknown SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 DUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO:
DUE TO ® Other/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE