HomeMy WebLinkAbout2025-00021494 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 6 Sheets 01111101111
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DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X003777215
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 3
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 202512025-00021494 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 'l
FRANKLIN BLVD El In 09:01
® ❑ RELATED ®Y 0 N 04 05 2025 ❑AM ®YES ❑NO U1 -<
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION M
FT!MI N E S W N LIBERTY ST COUNTY PROPERTY ❑Y ® N DOORING El #OF MOTOR 0 SLOW Cl)❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
FOR DAMAGEDAREA(S) FROPtf TOWED U1 0
Baeza.Jose 0 3 /
yr 13-UNDER CARRIAGE 161 ! 2 FIRE ❑ al
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL O4-TOTAL(ALL) DISTRACTED 0 0 U2 rrl
M 2 4 SYTM❑Y ®SNE❑UNK VEH. O ATCRASHD 0 15-99-UUNKNOWN THER9 t6•TOP 3 `Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 ;i�6 4 COM VEH 0 Ea 1
0
0
Z FIRST CONTACT 14 T ELG I N I L 60120 B 1 0 FE28322 I L ;REAR
_s Yes.See Sidebar Ut
TELEPHONE
IL D JA32W8FV9DU024514 State farm ®Y 0 N U2 19 . m
5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire Same Unknown 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Provena St.Joseph ❑Y El 2 ou
0 DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0
yr 12 _ C1
o 13-UNDER CARRIAGE 10 1 c. 2 FIRE ❑ ❑ U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 ❑ ❑ SPDR 0
❑Y ❑N 0 UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value U1 2 -
POINT OF s-.;, 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRSTO CONTACT Y 6 1j._s CIO Ms See SidebarEH
0 C
CO
F` REAR` co
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O
❑Y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
SAC
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
RESP❑YDNDER❑N U1 =
(UNIT) (SEAT) (008i (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0
1 3 09 /
DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 1 3 Comed ComEd Pole 04/05 /2025 09 01 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 ,,t 2 ❑ 34 3 1300 SPAULDING RD Elgin IL 60120 50 28 04,05 /2025 09 01 ®PM ❑Construction F
R 3 0 El CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME
z J ❑AM 0 Maintenance U2
-a, ARREST NAME Baeza.Jose 11-503—A-1 S1548-000017 04/05/2025 09 04 ®pM SLMT
o U 1 0 �!CITATIONS ISSUED 0 PENDING Utility
o N SECTION CITATION NO. ROAD CLEARANCE TIME AM' 0
t 2 El ARREST NAME Baeza.Jose 11-601—Ax S1548-000021 04/05 /2025 09 42 ®PM 0 Unknown work zone type U1 30
`n 2 3 ❑ OFFICER ID SIGNATURE BEAT I DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y
1548-Crandall. Matthew 301 05 ,05/2025 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 ----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 truckrtrailer -<
} } ' ' I - INDICATE NORTH combination):or -I
cJ i r BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
I _ (example:shuttle or charter bus):or C
if,i- I 3. Is designed tocarry 5 fewer passengers and operated a contract carrier O
eS 1 or
}.__-A-.--J. K } } transporting employees In the course of their employment(example:employee
a .! I transppoorterg-usually a van type vehicle or passenger car): r
} }
CO
Fr. e� ,, C
i. ...I. � � ` - 4. Is used ordesi natedtotrans rtbetween9and15passengers,includingthedriver,
b Fe l/.T7salllr. } } for direct compensation(example:large van used for speific purose):or
b
< .i. �._ " — — l. i } } t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
r placarding(example:placards will be displayed on the vehicle). ;p
r Fnn7 Mdehd , .1
CARRIER NAME Z
® 1 N..,I Q ® - ADDRESS D
14 rn
CITY/STATE/ZIP 0
Not 7b Scale f C
_ i. i. MOTOR CARR.ID 0 Interstate El Intrastate
1 1 r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
� "Y""1 USDOT NO. ILCC NO. m
XI
Source of above z
. own tank)? 0 Yes 0 No 0 Unknown —I
D
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes 0 No 0 Unknown g
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 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U_COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Silver
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Adieu/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U_DUE ETOO T6 DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BYl
DUE T VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE