HomeMy WebLinkAbout2025-00025555 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 4 Sheets II
III II IIIIII OUI 01100
0110
HIIUI
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003793953
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 2025I 2025-00025555 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
975 S STATE ST Elgin06:04
® ❑ 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 cn
❑ FT!MI N E S W Kane HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD DO
U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 NIAV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
0 3 !
yr 13-UNDER CARRIAGE .I FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 !O DISTRACTED 0 0 U2 2 m
M 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 _
❑N DUNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ ij 6 1 .4 COM VEH 0 0 1 C)
ZRolling Meadows I L 60008 B 1 0 DG73697 I L 2025 FIRST CONTACT 2 7_;REAR-OO =If Yes.See Sidebar U1 0
TELEPHONE
IL D 1 HGCV1 F4XNA036599 None ❑Y ❑N U2 13 . m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
co
Same None 2 m
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Refused El 23N 2 0
tg DRIVER 0 PARKED 0 DRIVERLESS ❑ PED 0 PEDAL 0 EWES 0 NUV ❑NCV 0 DV
!2 0 0 2 Toyota Corolla 2010' 00-NONE 11_"j Q�,-_, DUE TO CRASH rg ❑ 2 73
0o 13-UNDER CARRIAGE 10( I FIRE ❑ El U2 C
II
M 2 4 ❑Y ❑N ElUNK VEH. AT CRASH 99-UNKNOWN Oistrac)Dn Value 3
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR PFIRST CONTACT 1NT OF 2 O S li�-6 C•IOMs gee SidebarH ❑ U1 CO
— Elgin I L 60120 B 1 0 FF58987 I L 2025 REAR
O N
IL D 1 NXBU4EE2AZ275481 None ❑Y ❑N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same None BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT( (DOB) (SEX) {SAFT) (AIR) (INJI (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 ❑Y U2 Z
N 1 ® 11 1 04,23 l2025 06 04 ®❑pM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
Oi 2 0 11 1 28 15
! 1 ❑PM ❑Construction *
Z 3 0 Ei CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
o 1 ® 11 1 ARREST NAME Martinez,Jorge. L. 11-601-Ax 298001232 ! ! El PM SLMT
llg CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility
o N DI AM 40
Ti 2 0 11 1 ARREST NAME Martinez,Jorge. L. 3-707 298001233 1 ! PM 0 Unknown work zone type U1
2 2 3 0 OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME 0 AM Workers present? ❑Y 40
298-Lopez, Mirko 700 275-Engelke 05 , 12,2025 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 -' I. 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
- ------I---- IlD transporting employeened to s inthe course 5 or fewer passengers
rhea emaployment nd operated
xample:employeeMErter-usner
} } }
a van type
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I. < _a I.. 4. 1. I �sedord�llnatedtotransehrtbetween9andr15r) ssen rs,includingthedriver. C
Not To Scale I } •
} } for direct compensation(example:large van used for specific purpose):or
I. I_ ..I.. _I - - i i t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires 'D
rn
�. - I sr.ra placarding(example:placards will be displayed on the vehicle). ;p
Mt,.M, S__ ? CARRIER NAME
ill• ADDRESS O
0
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
I r ❑ Not in Comm./Govt. 0 Not in Comm./Other
;_...Y._._. - USDOT NO. ILCC NO. rn
XI
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' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Blue Black
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 VEHICLE CONFIG._CARGO BODY TYPE LOAD TYPE