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HomeMy WebLinkAbout2025-00022988 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 I01101100 1110111M 1111 Nil DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003784206 u, 2 U2 1 1 1 U116 u2 u, 1 u2 u, 1 u2 4 6 u, 1 U2 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW ' Elgin Police Department ONE PERSON'S ❑5501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash 0 AMENDED YR 202512025-00022988 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ALLER ST El In 02:54 ® ❑ RELATED 0 Y ®N 04 12 2025 ®AM YES ®NO U1 -< _ _ g PRIVATE mo !day!yr ❑PM FLOW CONDITION m FT l MI N E S W WILLARD AVE COUNTY PROPERTY ❑Y ® N DOORING El #OF MOTOR 0 SLOW Cl) ❑ Cook HIT&RUN El V ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUES 0 NOV 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0 FOR DAMAGEDAREA(S) FROM TOWED U1 Q StoryLerma.Amanda. D. 0 1 / yr 13-UNDER CARRIAGE ©) ©:. Z FIRE 0 ® E STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O O DISTRACTED 0 0 U2 m F 2 5 ❑Y ®SYSNEM❑UNK VEH. 0 ATCRASHD 99-UUTHER NKNOWN 9 t6•TIDP 3 `DistractionValue 9 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s_iL 6 I,.4 COM VEH ❑ Ea 1 O ~ Belvidere I L 61008 0 1 0 FIRST CONTACT 12 Y. _-5 *If Yes.See Sidebar Ut ZFE43225 IL 2026 TELEPHONE IL D 0 1 N4AL3AP8FC198753 Direct ❑Y ®N U2 13 . m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same 2027820298 1 r o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ❑ N 2 rg- ou 0 DRIVER ❑ PARKED ❑DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 NOV 0 i v 0 Dv yr 12 - C o 13-UNDER CARRIAGE 1U I 2 FIRE ❑ ❑ U2 C c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 ❑ 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 FIRST CONTACT TA—d:=5 C•IO e1sVEH See •Sidebar❑ 0 C CO F` PEAR` co M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O ❑Y ❑N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = BAC HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < RESP❑YO❑N NDER U1 = (UNIT) (SEATI (DOS) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0 / / U2 r m Pj / / UI 1 D 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 43 2 LOPEZ. NICOLAS Mailbox 04,12 ,2025 02 54 ®❑PM 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 v t 2 ❑ 540 ALLER ST ELGIN IL 60120 08 20 ! ! ❑PM ❑Construction Z3 ❑ I!II CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 -a, ARREST NAME Story Lerma.Amanda. D. 11-601 752034 ! r El PM SLMT o N 1 ❑ B!CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME Elutility ID AM 30 t 2 ElARREST NAME Story Lerma.Amanda. D. 11-708 752033 ! ! 0 pM ❑Unknown work zone type U1 n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y 2 3 ❑ 1532-Hernandez. Daniel 401 331-Ziegler , / ❑❑PM Workers present? ®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. Hasa weight rating more than 10,000 pounds(example:truck or truckrtrailer -< i- }__-_r_-_-; „off } combination):or INDICATE NORTH BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C - } (example:shuttle or charter bus):or :or \.7 T,3. is designed to car 15 or fewer ssen ers and o rated a contract tattler I O 0 , } -A- --1 - }j . . } } transporting employees in the course of their employment� (example:employee X co L �. _a....� transporter4 sed or d usually designated to transehrt betweeicle or n 9 and 15r) ssen rs,including the diver.} } for direct compensation(example:large van used for specific purpose):or 0 ` i..._.a.---� Not To Scale ' - L < < t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires •1 placarding(example:placards will be displayed on the vehicle). ,Zmj —1 CARRIER NAME Z - ADDRESS 0 T. rn CITY/STATE/ZIP n MOTOR CARR.ID 0 Interstate El Intrastate 0 1 I r 1 ❑ Not in Comm./Govt. 0 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 0 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U_COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Black 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 TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO: DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE