HomeMy WebLinkAbout2025-00017723 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
01101100 00 I I� 111100
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003762258
u, 1 U21 1 1 1 U199 U2 1 U, 1 1_12 1 U,99 U2 1 1 9 U1 99 U221 *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 1215501-$1.500 ®ON SCENE 7
VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00017723 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m
1660 LARKIN AVE Elgin01:56
® ❑ RELATED ❑Y ®N 03 20 2025 DAM ❑YES ®NO U1
_ PRIVATE mo /day/yr ®PM FLOW CONDITION m
COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ FT/MI NESW Kane 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 I] PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
/ ! FOR DAMAGEDAREA(S) FRONT TOWED U1 0
unknown Unknown Unknown 00-NONE it.. 12 , OUETOCRASH ❑ EN
NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE IE
10 !!. 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED U2 0 <
2 4 SYSTEM IN 9 ENGAGED 9 15-OTHER 9 16.TOP 3 ❑ _
❑Y ElN ®UNK VEH. AT CRASH 99-UNKNOWN $ 4 `Distraction Value 9 ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF iL 6 �i C.OM VEH El �! 1 00
1— 99 FIRST CONTACT 7_;—, 5__ *lIYes.See Sidebar U1
0 1 0 UNKNOWN RE
2 Z
_ TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1
UNKNOWN ❑Y ❑N U2 I—
.5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same UNKNOWN 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF`Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 99 0
0 DRIVER X. PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 uv 0 K V 0 Dv
yr Hyundai Santa Fe 2015 00-NONE ,1_' t2 _, DUE TO CRASH ❑ ® 1
O 13-UNDER CARRIAGE I 2 FIRE El El U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED
a SYSTEM IN 0 ENGAGED 0 15-OTHER 016•TOP 3 0 ® SPDR 0
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value U1 0 -
POINT OF s ) -4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR S !._ C.OM VEH ❑ ® CO
F,,, FIRST CONTACT 9 7 _, _5 •If Yes.See Sidebar
AR41434 IL I:EaR 0 Si)
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
SXYZU3LB7FG271859 State Farm 0 V ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Martinez,Abigail 0233042SFP13 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) OM (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
0 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 18 5 03,20 l2025 01 56 ®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
2 0 18 99
N 3 0 CITATIONS ISSUED 0 PENDING + ! 0 PM• El Construction
SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
2
-a, ARREST NAME / / El PM
ou ® _11 1 0 •CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT
t 2 El ARREST NAME 03 r 20 l2025 ❑❑PM ❑Unknown work zone type U1 10
x AM
T
n OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 — ❑AM Workers present? ❑Y 1 O
1535 Solis• Laura sot , ❑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.
0
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---.;-----; ; -
o-N- INDICATE NORTH combination):or
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i l _ (example:shuttle or charter bus):or n
Not To Sonia X
5 or fewer
< ------;----; transporting employeened to s Inthe course passengers
rhea emaployment nd operated
xample:employeener O
} } }
transporter-usually a van type vehicle or passenger car):or CO
C
L L.__-a-_- _ 4. Is used ordesi natedtotrans rtbetween9and15passengers,includingthedriver• } } for direct compensation(example:large van used for speific purose):or 0
c
I I. i i ._ 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). m
73
CARRIER NAME Z
ADDRESS 0
to
n
CITY/STATE/ZIP E
�, J - 1t. MOTOR CARR.ID 0 Interstate ❑ Intrastate -�
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other 0
--- --4. - USDOT NO. ILCC NO. m
m
' Source of above Z
. GVWR/GCWR m
El <10,000 El10,000-26,000 0 >26,000
-•I
Were HAZMAT placards on vehicle? 0 Yes 0 No —t
If Yes,Name on placard 0
4 digit UN NO. 1 digit Hazard class No.
x
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z
own tank)? 0 Yes 0 No 0 Unknown D
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes ❑ No ❑ Unknown
D
Did Carrier Safety Regulations(MCS)violation contribute to the crash?
❑ Yes II No El Unknown Unknown 0
Was a driver/vehicle Examination Report Form completed? D
HAZMAT ❑Yes 0 No ❑Unknown Out of Service ❑Yes ❑No 7(1
MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No 5
Z
Form Number o
_ m
x
IDOT PERMIT NO. WIDELOAD' ❑Yes 0 No =
' TRAILER VIM 1 _ m
LOCAL USE ONLY TRAILER VIN 2 m
— O
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 0 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft N
Orange
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 9 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE