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2025-00025559
ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 01101100 01111111 1110 III DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003793937* u, 1 U2 1 1 2 U, 4 U2 U, 1 1_12 U, 1 U2 1 1 9 U1 1 U221 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW ' Elgin Police Department ONE PERSON'S El5501-51.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash El AMENDED YR 2025I 2025-00025559 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn 475 SHADY OAKS DR Elgin06:45 ® ❑ RELATED ❑Y ®N 04 23 2025 ®AM ❑YES ®NO U1 -< _ PRIVATE mo /day/yr ❑PM FLOW CONDITION m COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n ❑ FT/MI NESW Cook HIT&RUN ❑V ® N WITH VEHICLESOT, INVLD ❑ STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Q83 DRIVER t] PARKED O DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C) .FROM Ve a.Jaime Acura TSX 2006 00-NONE zT TOWED U1 Q , DUE TO CRASH ® ❑ NAME(LAST,FIRST,M) g mo yr 13-UNDER CARRIAGE ©, �._Z FIRE ❑ IE < STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 m M 2 4 ❑Y ®SNE❑UNK VEH. O ATCRASHD15-OTHER O 99-UNKNOWN 9 16•TOP 3 `Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�a �i 4 COM VEH 0 j$J 1 0 ELGIN I L 60120 B 1 0 FIRST CONTACT 11 7_: __5 *Ilyes.See Sidebar U1 Z FC77045 IL 2026 REAR TELEPHONE IL D 7 JH4CL96806CO29509 NIA ❑Y ❑N U2 I- 5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m co Elgin Fire 1 99 9 Same NIA 2 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D St.Alexius Medical Center ❑Y El 9 2 0 0 DRIVER N. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 row 0 NOV 0 DV yr 12,; 0 13-UNDER CARRIAGE 1a) I. E FIRE ❑ ® U2 C c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR C) SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP 3 9 3 X a ❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN *Distraction Value POINT OF 8 ) 4 U1 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 12 Y ij 6 i'._ C•IOMs geeSidebar❑ ® C CO ~ DN16182 IL 2025 REAR 9 fp M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 2T1 BURHE5EC160972 MAGNUM INSURANCE ❑Y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 1 99 9 GAMARRA FARFAN. HECTOR.J. IP2825277 BAC $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (008) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 18 2 Clark.Gregory.V. mailbox 04,23 ,2025 06 45 ®❑pM in a Work Zone? ®N DIRP co 1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1 v 2 ❑ 1 475 SHADY OAKS DR ELGIN IL 60120 28 15 04,23 ,2025 06 45 ❑PM ❑Construction >E ru 3 ❑ 40 3 $I CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ®AM ❑Maintenance U2 a 1 ER 11 1 ARREST NAME Vega.Jaime 6-101 374001312 04,30 r2025 06 54 ❑PM UtilitySLMT El CITATIONS ISSUED 0 PENDING o N SECTION CITATION NO. ROAD CLEARANCE TIME AM 25 F 2 El ARREST NAME Vega.Jaime 11-601—Ax 374001314 04/23 r2025 07 44 MPM El Unknown work zone type U1 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 25 374-Rizzu-o. Michael 202 06 ,03,2025 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 truck trailer -< i- }---_r---- 8.., combination):or —I INDICATE NORTH X1 h� „o i BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ' °jip _ } (example:shuttle or charter bus):or C ' r r r ` ` A 1:4P' N 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O } } } transporting employees In the course of their employment(example:employee 73 smasronnonxs ,�. transporter-usually a van type vehicle or passenger car):or co L DR 1. 4. Is used or designated to transport between 9 and 15 passengers,including C -- } } } g po passen rs,includi the driver, +, no4� for direct compensation(example:large van used for specific purpose):or o ---' .•, Not To Scale j , __ :� �_ } } } t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m ( placarding(example:placards will be displayed on the vehicle). X/ VII —I CARRIER NAME Z ` _ ADDRESS 0 W C) 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 ‘I. - --1 - USDOT NO. ILCC NO. m XI Source of above z . 0 Yes ❑ No 0 Unknown M D Did Carrier Safety Regulations MCS)violation contribute to the crash? A 0 Yes II El Unknown C Was a driver/vehicle Examination Report Form completed? r HAZMAT ❑Yes 0 No ❑Unknown Out of Service ❑Yes ❑No : MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No C Z Form Number 0 m 71 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 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Silver Grayw u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® Redmons/Owners Residence VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE