HomeMy WebLinkAbout2025-00025685 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY El OVER$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 2025I 2025-00025685 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED PRIVATE ❑Y ®N 04 23 2025 ❑AM ❑YES ®NO U1
E HIGHLAND AVE Elgin mo /day/yr 05:02 ®PM FLOW CONDITION m
®1540!MI NOS W North State St COUNTY PROPERTY ❑Y ® N DOORING ICI #OF MOTOR 0 SLOW 1 cn
Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --1
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
(g)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 3 0
FOR DAMAGEDAREA(S) FRObff TOWED U1 O
Sostre.Jose h.A. 1 1 /
yr 13-UNDER CARRIAGE ) 2 ' 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 3 <<T1
M 2 SY4 ❑Y ®SNE❑UNK VEH. O AT CRASM IN H O 99-UNKNOWN 9 76•TOP 3 `Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ ;iI a 4 COM VEH 0 El 1 0
~ ELGIN IL 60120 0 1 0 FIRST CONTACT 12 7 ;1 _5 *IIYes.See Sidebar U1
Z EX26593 IL 2025 isui
TELEPHONE
IL D 0 3FA6P0H73DR269080 Travelers Indemnity Compa ❑Y Il N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR 1-1
99 9 Elgin.City.o. 8109160P901 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER
2 73
x DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑
1 9 8 9 Chevrolet Impala 2007 00-NONE ,i"j t2..-_, DUETO CRASH ❑ cg 2 73
o 13-UNDERCARRIAGE 10;1 2 FIRE ❑ ® U2 C
c
M 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP 3 X
0 Y Ni N 0 UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value 0
POINT OF s iI 4 COM VEH 0 ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 5 �'_
FIRST CONTACT 6 Y__{_0 _5 C.If Yes.See Sidebar
= South Elgin IL 60177 0 1 0 V126982 IL 2025 REAR 0 Si)c
IL B 0 2G 1 WC58R679191840 State Farm ❑Y ®N RDEF 7:1
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
99 9 Same 2735237SFP13 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
u 1 ® 11 1 41 ,31 )025 05 02 ®AM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
0 2 03 99 ) ) 0 PM ❑Construction *
Z3 0 lyg CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2
a ® 11 1 ARREST NAME Sostre.Joseph.A. 11-710-A W1528-000254 / r El PM SLMT
o N 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility
0 AM
t 2 ❑ ARREST NAME 4) +3) 1025 05 10 0 PM El Unknown work zone type U1 25
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ ❑AM Workers present? ❑Y 25
1528 Rivera. Kevin 601 223-Hughes / ❑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 truckrtrailer -<
c ` -' -' r INDICATE NORTH combination):or .Z-1
I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} I - ,. (example:shuttle or charter bus):or 0
4^ ,,,�,,,, 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier O
< } -A----i i.` urn } r } transppoorterr- lyavantypcvehicleorpirempbymar):or mple:employee
_ usually type passenger car):or CO
L L.___a____.I ; un �4310 — _ I.
} } } •4. Is used or designated to transport between 9 and 15 passengers,indudingthe driver. C
for direct compensation(example:large van used for specific purpose):or
L L--_-a-....l r I_ - t 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
—1
CARRIER NAME Z
ADDRESS 'n
nru 7a Scale ' V)
CITY/STATE/ZIP 0
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
I r ❑ Not in Comm./Govt. 0 Not in Comm./Other
; _Y___-1 - USDOT NO. ILCC NO. m
Source of above z
. MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No 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 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Gray Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 0 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE