HomeMy WebLinkAbout2025-00026052 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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VII 10110 1110
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003797117-
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INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 3
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 202512025-00026052 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 7 mRT20 EB El07:50
® ❑ RELATED ❑Y ®N 04 25 2025 ®AM ❑YES ®NO U1
_ _ g PRIVATE mo !day/yr ❑PM FLOW CONDITION m
FT!MI N E S W S STATE ST COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR El SLOW 15 Cn
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ® STOPPED U2 --I
Igl AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 Nuv 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0
FOR DAMAGEDAREA(S) FROf tf TOWED U1 Q
LOPEZ LOPEZ.JORGE. E. 0 8 /
yr 13-UNDER CARRIAGE 101 ! 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 4 rn
M 2 SY n 15-OTHER
4 ❑Y ®SNE M❑UNK VEH. AT CRASH IN n D 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 7 7_. --iI B �i COM VEH 0 j$J 1 0
F. FIRST CONTACT 1 ___5 *Irves.See Sidebar Ut
Z STREAMWOOD IL 60107 0 1 0 P1069598 IL 9999 T' ;
TELEPHONE
IL B 7 1 HTGSSNT6GH738858 ARCH INSURANCE CO. ❑Y J N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
BONE ROOFING SUPPLY ZACAT9258606 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER >
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g DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 ivy 0 Ncv 0 Dv
!1 9 8 2 Dodge Journey 2020' 00-NONE 11"j t2 FRONT TOWED
DUE TO CRASH ❑ 2 x
0r 13-UNDER CARRIAGE 10'( 2 FIRE ID ® 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 *0istracl on Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF & S I.,:_ COM VEH D ® Ut CO
F,,, FIRST CONTACT 7 O7 _, _5 •(ryes.See Sidebar
ELG I N I L 60123 B 1 0 EW33099 I L 2025 I 0
Z
IL D 0 3C4PDCGB5LT263622 GEICO ❑Y ®N RDEF P3
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 2006479683 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND 0 N U1 =
(UNIT) (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 ®Y U2 Z
N 1 ® 11 1 04,25 l2025 07 50 ®❑pM in a Work Zone? ❑N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
0
1
2 28 99 + ! ❑PM ❑Construction *
Z 3 0 lyg CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM ❑Maintenance U2
a LOPEZ LOPEZ.JORGE. E. 11-601 244-1808 / ! PM
-, ARREST NAMEEl
oN ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT
t 2 ElAM i
ARREST NAME 1 r ❑❑PM ®Unknown work zone type U1 45
2 2 3 ElOFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 45
244-Blomberg. Michael 701 05 ,27,2025 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 -<
c ` --I -' r INDICATE NORTH combination):or .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- } (example:shuttle or charter bus):or
X
3. Is designed to carry15 or fewer passengers and operated a contract carrier O
}----------i
Not7b Scale } } } transporting employees in the course ofo employment caant(example:employee 73
_� transporter-usually a van type vehicle or passenger car):or co
L L.___a__ 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or
rwvrr=
71
a . i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
t placarding(example:placards will be displayed on the vehicle).
uon+ z XI
raouTerm — CARRIER NAME
Z
ADDRESS 0
w
n
CITY/STATE/ZIP E
MOTOR CARR.ID 0 Interstate 0 Intrastate
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
----'Y----1 - USDOT NO. ILCC NO. rn
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?
❑ Yes II No ElUnknown A
Was a driver/vehicle Examination Report Form completed? r
HAZMAT ❑Yes 0 No ❑Unknown Out of Service ❑Yes ❑No 7
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
v
TRAILER WIDTH(S) 0-96" 97-102" >102' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. y
Red Black
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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE