HomeMy WebLinkAbout2025-00025208 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 a Sheets 01111101111
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DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003791859*
u, 9 u21 1 1 1 U,10 U2 1 U199 1_12 1 u1 99 U2 99 5 12 u, 2 U2 1 *P 0119*
INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 2025I 2025-00025208 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 71
S STATE ST Elgin08:29
® ❑ RELATED ❑Y ®N 04 21 2025 ❑AM ❑YES El NO U1 —<
_ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION m
FT!MI N E S W W CH ICAGO ST COUNTY PROPERTY El 21N DOORING Ely #OF MOTOR 0 SLOW 1 (n
❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD ❑ STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑uuv ❑!Cy ❑ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
! ! FOR DAMAGEDAREA(S) FROPtf TOWED U1 Q
Unknown.0. Toyota CAM RY 2013 00-NONE „ 12 , DUE TO CRASH 0 NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 101 ! 2 FIRE 0
IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
9 9 Y SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 9 ALGN =
❑ ❑N ❑UNK VEH. AT CRASH ®-UNKNOWN `Distraction Value
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6_iL 6 j!.4 COM VEH ❑ )g! 2 O
I— 0 9 FIRST CONTACT 99 7_; __5 *IIVes.See&debar U1
ZAT43492 IL 2020 REAR
TELEPHONE
4T4BF1 FK3DR321004 Unknown ❑Y 0 N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
a
Hagos. Filmon Unknown 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
'‘.3RESPONDER ( G0)
m N DRIVER 0 PARKED ❑DRIVERLESS ❑ PEo ❑PEDAL ❑EWES ❑ uv 0 NCv ❑Dv
yr Mitsubishi Lancer 2009 oo-NONE O, M 0i.0 DUE TO CRASH ❑ 2 x
o _ 13-UNDER CARRIAGE 10� D 2 FIRE ❑ El U2 C
c
M 2 4 SYSTEM IN ENGAGED 15-OTHER 9 16•TOP 3 9 4 X
❑Y ❑N DUNK VEH. AT CRASH 99-UNKNOWN *Oistraceon Value
POINT OF s i 4 COM VEH D ® u1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6 �S_. 0
FIRST CONTACT 1 7 _, _5 •If Yes.See Sidebar
ELGIN IL 60123 0 1 EQ41363 IL REAR
4 N
Z
IL 0 JA3AU16U19U005849 Bristol West Insurance Co ❑Y J N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Ortiz. Norma. P. G01153900804 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (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 0 Y U2 Z
N 1 ® 11 1 04,21 /2025 08 30 0 AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
2 ❑ 20 04
N 1 3 ❑ 0 CITATIONS ISSUED 0 PENDING ? / ❑PM• El Construction
SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
—a, ARREST NAME / / ❑PM
1 ® 1 1 1 0 CITATIONS ISSUED 0 PENDING • UtilitySLMT
o N SECTION CITATION NO. ROAD CLEARANCE TIME 0
r 2 ❑ ARREST NAME 04?21 12025 08 33 ®PM El Unknown work zone type U1 0 AM
35
x T
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
❑Y 35
1525-NavE.Oscar 601 - ? ! 0 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----T- , , \\ _ ; 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
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
YIf7Cli f: \ \ _ (example:shuttle or charter bus):or 0
3. Is desgned to carry15 or fewer passengers and operated a contract carrier O
-- \
} } } transporting employee In the course of their employment(example:employee
i 1 . 1 transporter
used or designated
nated to po between 9 and 15 passengers,or co
` C
}--- } } } g transport including the driver. to
Not To Scale 1 for direct compensation(example:large van used for specific purpose):or
L____a____. \ ‘I''
_ t i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
Z placarding(example:placards will be displayed on the vehicle). XI
\ter
\ It,o. CARRIER NAME Z
O
\ o __ ADDRESS T.
rn
\ \ n
CITY/STATE/ZIP 0
MOTOR CARR.ID 0 Interstate 0 Intrastate
\ \ ❑ Not in Comm./Govt. ❑ Not in Comm./Other 00
--- --1 \ - E USDOT NO. ILCC NO. C
m
XI
Source of above 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 ElYes 0 No ❑Unknown Out of Service ❑Yes ❑No Ti
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
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
Green.Dark Silver
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 9 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