HomeMy WebLinkAbout2025-00018407 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100 00 ID HOD
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ❑sso,-g1,500 ®ON SCENE 15
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 2025I 2025-00018407 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 71
VILLA ST Elgin 07:42
® ❑ RELATED ®Y 0 N 03 23 2025 ❑AM ❑YES ®No u1 -<
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION M
FT!MI N E S W ST CHARLES ST COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 2 fA
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
0 DRIVER ❑ PARKED ❑DRIVERLESS N PED 0 PEDAL 0 EWES 0 MAU 0 wcv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
0 3 /
yr 13-UNDER CARRIAGE 101 2 FIRE ❑ 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 1T1
M SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 _
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ ;i�a 4 COM VEH ❑ ❑ 4
0
0
ELGIN IL 60120 A FIRST CONTACT 15 7 ; _5 •II Yes.See Sidebar U1 2
REAR
2 Z
TELEPHONE
IL ❑Y 0 N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
co
Elgin Fire 1 52 2 2 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER AA
RESPONDER
Provena St.Joseph ❑Y ❑ N
Eg DElVER ❑ PARKED ❑DRIVERLESS 0 FED 0 PEON. 0 EWES 0 NOV 0 NOV 0 DV
/1 9 8 4 Ford F150 2019 00-NONE 11_"j ni-_, DUE TO CRASH ❑ 2 x
O y Yr 13-UNDER CARRIAGE 10( I 2 FIRE ❑ ® U2 C
c
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistraci n Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s_.il�.:,_4 COM VEH ❑ ® U1 W
FIRST CONTACT 12 7 •.5 •(ryes.See Sidebar
= ELGIN IL 60123 0 1 0 2610418B IL I C
0 Si)
IL D 0 1 FTMF1 EB6KKC23117 unknown ❑Y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
PIZZO&ASSOCIATES L unknown BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP 996 <
Refused RESPONDER
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) OHJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/{ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
2 3 10 / F 12 4 0 1 0
m
/ / #OCCS D
Pj
/ / UI ' D
/ / 2 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 12 4 31 /31 /025 07 42 0 AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES Check one below: 0
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AMU1
2 25 99 31 ,31 /025 07 42 ®PM ❑Constrticr, *
R O ❑ zi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
3 ❑AM ❑Maintenance U2
o ® 12 4 ARREST NAME Villafane. Ramon.A. 11-307-B 482000504 31 /31 /025 07 43 ®PM• • El Utility SLMT
MI CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME
p N ❑AM
T 2 ElARREST NAME Rozgus.Alicia. M. 3-707 482000503 31 /31 /025 08 48 ®PM ❑Unknown work zone type U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 30
482-Flentye.Jeremy 301 391-Jacobucci 51 / 12 /25 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 ----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 -<
` ` -'- ' r INDICATE NORTH combination)or 5311
r 4.. BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ } (example:shuttle or charter bus):or
N X
L A I 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
t } } } transporting employees In the course of their employment(example:employee X
�i wWM € z transporter-usually a van type vehicle or passenger car):or co
C
< < _a_
-- I '1 :-"''�- } 1} 4. Is used or designated to transport between 9 and 15 passengers,including the driver,.
for direct compensation(example:large van used for specific purpose):or O
` -..._a---- Not To Scale - l. It 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
' placarding(example:placards will be isplayed on the vehicle). m
- -- —1
CARRIER NAME XI
ADDRESS 'n
V)
C)
CITY/STATEJZIP g
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
I I T ❑ Not in Comm./GaA. Not in Comm./Other
‘I. - --1 USDOT NO. ILCC NO. m
XI
Source of above z
. 0 Yes II 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
0
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE