HomeMy WebLinkAbout2025-00024901 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 01101100 1VVI11fl10011110000
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 15
VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
0 AMENDED YR 202512025-00024901 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I
395 RAYMOND ST Elgin01:32
® ❑ RELATED 0 Y ®N 04 20 2025 ❑AM ❑YES ®NO U1 -<
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW Cl)
❑ FT/MI NESW Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEOAL 0 EOUES 0 NW/ 0 ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
Meza Perez. Romulo. R. 1 2 /
yr 13-UNDER CARRIAGE tar , 2 FIRE 0 ® C
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 M
M 2 4 ❑Y ❑SYN SE CD UNK VEH. 9 AT CRASH M IN ENGAGED9 99-UUNKNOWN Ole-TOP 3 `Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, 0
F• FIRST CONTACT 12 7__iL B 4 COM VEH 0 j$J 1 0
;-, _5 *Irves.See Sidebar U1
V Z Sleepy Hollow IL 60118 0 1 0 DW73203 IL 2025 REAR
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED
6 ( 5N1ED28Y32C548071 No Insurance ❑Y ❑N U2 r
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Gonzalez Meza. Ingrid Gua.G. No Insurance 2 r
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 X
0 DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 iiuv 0 i v 0 Dv
yr 12 _ 71
o 13-UNDER CARRIAGE 1U I c. 2 FIRE 0 0 U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 0 0 SPDR 0
0 Y ❑N 0 UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value U1 4 -
POINT OF s-.;, -4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT Y�='+:-5 COM•I sVEH See •Sidebar❑ ❑ C
CO
F` pEAR` C
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 <
RESPNDER❑YD❑N U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0
W 06 /
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 43 3 Elgin Tree with white blossoms 04/21 /2025 01 35 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 10
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
v t 2 0 150 DEXTER CT ELGIN IL 60120 08 20 ) ! 0 PM ❑Construction >F
Z3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2
-a, ARREST NAME / / El PM '
o N 0 ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
SLAT
30
t 2 ARREST NAME AM
T 1 r ❑❑PM 0 Unknown work zone type U1
El
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y
2 3 0 ❑AM Workers present? 0
1545 VanEycke. Brier 401 310 Zierk r / ❑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
r CO : _ combination): r more than pound (example:truck or truck/trailer
1. Has a weight rating10 000 5
INDICATE NORTH o p3
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver —I
-<
` Not To Scelo vr_� a% rn0� } (example:shuttle or charter bus):or 0
l .t .7 i o, 3. Is designed to carry 15 or fewer passengers and operated a contract carrier 0
-�/ } } } transporting employees In the course of their employment(example:employee
_ � transporter-usually a van type vehicle or passenger car):or w
i'�'�■■■■■� 4. Is used or designated to transport between 9 and 15 passengers,including C
i. }-----}----; - I. } } } g po the driver,
�� for direct compensation(example:large van used for specific purpose):or O
L l. ii. t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). XIl � D
CARRIER NAME Z
Z
ADDRESS 0
CITY/STATE/ZIP C)0
MOTOR CARR.ID 0 Interstate ❑ Intrastate 5
Rai r ❑ Not in Comm./Govt. ❑ Not in Comm./Other 0
‘I. - --1 USDOT NO. ILCC NO. m
m
M
Source of above z
IDOT PERMIT NO. WIDELOAD"; ❑Yes 0 No =
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
Tan
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
Redmons/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET
U_DUE ETOO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO:
DUE T VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE