HomeMy WebLinkAbout2025-00023333 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
I01101100 VII I III I DVI DO
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X403783913
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INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00023333 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
SUMMIT ST Elgin 07:10
® ❑ RELATED ❑Y ®N 04 13 2025 ❑AM ❑YES ®NO U1
g PRIVATE mo /day/yr ®PM FLOW CONDITION Ill
FT!MI N E S W SHADY OAKS DR COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 15 u)
❑ Cook HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EDUCE ❑NOV 0 Ncv ❑ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 5 0
0 9 /
Mitsubishi Galant 2011 oo-NONE „_• Oi_, DUE TOCRASH ❑ ® E
13-UNDER CARRIAGE 10 i , 2 FIRE 0 NI
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED THER ❑ 0 U2 5 r<rl
M 2 4 SYTM❑Y OS NE❑UNK VEH. 0 AT CRASH 0 15-99-UUNKNOWN 9 76•TOP 3 *Distraction Value 7 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 7_iL a I,.4 COM VEH El g! 1 0
F. FIRST CONTACT 12 _)—, _5 *Yves.See Sidebar U1
Z STREAMWOOD IL 60107 0 1 0 EV13252 IL 2025 REAR
TELEPHONE
IL D 0 4A32B2FF2BE017878 STATE FARM ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
ORTIZ.ALEJANDRO.T. 2055286SFP13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER
RESPONDER
2
p; DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑row 0 NOV 0 Dv
/1 9 yr 9 Toyota Highlander 2014 00-NONE ,� 12 , DUE TO CRASH p (� 2
0 13-UNDER CARRIAGE 10 1 2 FIRE ❑ ® U2 C
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 5 iI S l',_4 COM VEH D ® Ut CO
FIRST CONTACT 6 Y__{_O ._5 •If See Sidebar
= ELGIN IL 60120 0 1 0 BA93994 IL 2025 REAR
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IL D 0 STDKKRFH5ES034038 STATE FARM ❑y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
WILLIAMS.JONATHAN. K. 0887856-SFP13 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE:ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((A.DDRESS)((TELEPHONE) (EMS) (HOSPITAL)
2 3 12 / M 2 3 0 1 0
m
/ / #OCCS D
/ / U1 1 D
/ / 2 O
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
u 1 ® 11 1 4/ ,3/ /025 07 10 ®PM in a Work Zone? ®N DIRP co
1 1 PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
0 2 40 28 / / ❑PM ❑Construction *
R 3 ❑ $I CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM ❑Maintenance U2
a ORTIZ.JONATHAN 11-601 W1519-000317 / / PM
-, ARREST NAME ❑
o N 1 ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT
35
t 2 ARREST NAME AM
/ / ❑❑PM ❑Unknown work zone type U,
El
7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ - ❑AM Workers present? ❑Y 35
1519-Bae2 a.Guadalupe 201 / / ❑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 -<
c ` --I -' r INDICATE NORTH combination):or .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
I - } r r r (example:shuttle or charter bus):or 0
1 scree 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
I - . - . transporting employees in the course of their employment(example:employee X
"""""' transporter-usually a van type vehicle or passenger car):or w
L L.___a__._.l ---- _ - 4. Is used ordesinatedtotrans rtbetween9and15passengers,includingthedriver. C
I d� • } } •
for direct compensation(example:large van used for speific purose):or 0
L a----. - t l I I 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
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placarding(example:placards will be displayed on the vehicle). ,Zmt
- —I
CARRIER NAME Z
ADDRESS
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r r T 1 I ..,L,7 i. i. i. i. 4.
CITY/STATE/ZIP 0
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MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
------- --1 - USDOT NO. ILCC NO. rn
XI
Source of above Z
. —I
Were HAZMAT placards on vehicle? 0 Yes 0 No =
If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. Xl
Xl
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 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
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Red Green
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 1 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE