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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ❑5501-51.500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
El AMENDED ElB Injury and for Tow Due To Crash YR 202512025-00022474 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 71
® ❑ RELATED ®Y 0 N 04 10 2025 ®AM ❑YES ®NO U1 —<
N STATE ST Elgin06:10
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FT!MI N E S W TOLLGATE RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 6 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD DO
U2 —I
El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
QT3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
0 7 !
yr
Kia Motors Co rento 2014 00-NONE „ i OUETOCRASH ❑ EN
13-UNDER CARRIAGE fat 12 2 FIRE 0 IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 0 m
F 2 SY 15-OTHER
4 ❑Y ®SNE❑UNK VEH. 0 AT CRASM IN H 0 99-UNKNOWN 9 16•TOP 3 `Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 7 i� a �r.4 COM VEH 0 j$J 1 n
~ ELGIN I N I L 60120 0 1 0 FIRST CONTACT 5 7 : _O •Ir Yes.See Sidebar U1 0
Z AB63429 IL 2025 REAR
TELEPHONE
IL D 5XYKWDA74EG488459 State Farm ❑Y ®N U2 Si . m
.5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
co
Same 2633381SFP13 2 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ElN 2 0
g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NAV 0 NCv 0 Dv
/1 9 9 8 Ford F550 2015 00-NONE i1_"j Q�,-_, DUE TO CRASH ❑ ® 14 x
0 Yr 13-UNDER CARRIAGE 10( I FIRE ❑ ® U2 C
c
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `0istracton Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-iI�1:,-4 COM VEH ❑ ® U1 CO
FIRST CONTACT 12 7 .5 •It Yes.See Sidebar
REAR C
Z Carpentersvillle IL 60110 0 1 0 487136D IL 2025 N
D
IL D 1 FDUF5GT3FEC93056 Pekin ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Battaglia Industries 5864440 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 4 04,10 l2025 06 10 ®❑AM
in a Work Zone? ®N DIRP co
1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 1 C)
T
5'
2 0 2 28 1 1 ❑PM• ❑Construction *
Z 3 0 1!>I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
a1 ® 11 4 ARREST NAME Martinez, Maria,G. 11-801-B 298001226W / ! ❑PM SLMT
o N 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
45
r 2 0 ARREST NAME AM
T 1 r ❑❑PM 0 Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT I DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 45
298 Lopez• Mirko 8826 275-Engelke , ! ❑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 -<
` ` --I -' r INDICATE NORTH combination):or —I
i i I ' BY ARROW 2 Is used or designed to transport more than 15 C
`- I yl I g sp passengers including the driver n
} ' - } (example:shuttle or charter bus):or
L T,
3. Is desgned to carry 15 or fewer passengers and operated by a contract carrier I O
} } } transporting employees In the course of their employment(example:employee X
' transporter-usually a van type vehicle or passenger car):or w
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__ �`'% _ •} } } 4. Is used or designated to transport between 9 and 15 passengers,including the driver, N
S for direct compensation(example:large van used for specific purpose):or O
L L____a____.I < < < t 5 Is an vehicle used to transport an hazardous material(HAZMAT)that requires
t 4' Not To Scale placarding(example:placards will be displayed on the vehicle). M
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1 — — CARRIER NAME Z
_ __ ADDRESS 0E
I I $h 1 I CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
; _Y_ __.; - USDOT NO. ILCC NO. m
XI
Source of above z
. Form Number
m
Xl
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
to
LOCAL USE ONLY TRAILER VIN 2 m
v
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
Gray White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 2 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/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE