HomeMy WebLinkAbout2025-00027852 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
IIIIII 11 1111011 00101 1110
DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X003604647-
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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 1
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) El B Injury and/or Tow Due To Crash
El AMENDED
YR 2025I 2025-00027852 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r7
® ❑ RELATED ❑Y ®N 05 02 2025 DAM YES ®NO U1 -<
DOUGLAS AVE Elgin 11:33
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION III
q0 !MI N E S W East Highland Ave COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 cn
Ixl- ® O g Cook HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEOAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FR OP,r TOWED U1 O
NAME(LAST,FIRST,M) mo yr
Moreno Jr.Samuel Nissan 350Z 2004 00-NONE „ 12 , DUE TOCRASH ® ❑
13-UNDER CARRIAGE 101 ! 2 FIRE ❑ al
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14--TOTHER
OTAL(ALL) DISTRACTED 0 0U2 2 M614 M 2 4 ❑Y SYSTEM
❑UNK VEH. AT CRASHD 99-UNKNOWN 9 16.70P 3 ,Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ ;il a 4 COM VEH 0 )0 1
I- 60110 0 1 FIRST CONTACT 12 7 ;1 _5 *uves.See Sidebar U1 0
Z EW59281 IL 2025 Isui
TELEPHONE
IL D J N 1 AZ34D44T160821 State Farm Insurance ®Y ❑N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
co
Same Unknown 2 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y ® N 3 2 c
m N DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEOAL 0 EWES 0 row 0 K V 0 Dv
/2 0 0 5 Ford Mustang 2023 00-NONE ,i_-1 t2..-_, DUETO CRASH 0 Ig 2
o 13-UNDER CARRIAGE 101; 2 FIRE ❑ ® U2 C
c
M 2 4 SYSTEM IN 0 ENGAGED 0 ®-OTHER 9 16.70P 3 3 X
❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN *Oistrac on Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8
I- If Yes.See Sidebar 4 COM VEH D ® U1 CO
6
FIRST CONTACT 6 7AI'_5 • C
H Woodstock IL 60098 0 1 FC27082 IL 2025 PEAR3 Si)
IL D 1 FA6P8CF9P5300191 State Farm Insurance ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 Same 35237030-SFP-13 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER
® 3 U1 =
{UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS)/(TELEPHONEI (EMS) (HOSPITAL)
W / / F
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UI 1 D
/ / 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 05,02 /2025 11 33 ®AM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
v 2 ❑ 28 15 05,02 /2025 11 36 ®PM ❑Construction *
R 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
z J ❑AM ❑Maintenance U2
o 1 ® 11 1 ARREST NAME Moreno Jr.Samuel 11-601 359000620 05/02/2025 11 41 ®pM SLAT
j$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM• ❑Utility
t 2 El ARREST NAME Moreno Jr.Samuel 11-1427-H- 359000619 05/03 /2025 00 15 MPM ElUnknown work zone type U1 30
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? D Y 3U
359-Williarhson. Linda 101 06 , 10,2025 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 truckrtrailer -<
- }__-_r_-__1 I. INDICATE NORTH combination):or
—I
NOTTORAwN7r04dCAL! t i l O BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ` W FN } e. r t- (example:shuttle or charter bus):or 0
< <---- -•-•; transporting mployeened to sl5 or fewer in the course passengers thir emplod yment example:employee
transporter
ii.F } } }
L ----------� Ei / - } } } } • sed or des gnated to transport between 9 and r 15rpassengers,including the dryer, y
for direct compensation(example:large van used for specific purpose):or O
' L____a____. _ i i _ 5. Is anyvehicle used to transport anyhazardous material(HAZMAT)thatrequires
m
— —c�+- - placarding(example:placards will be displayed on the vehicle). xi
COMM -1
1
CARRIER NAME Z
ADDRESS 0V)
CITY/STATE/ZIP
I - MOTOR CARR.ID 0 Interstate El Intrastate
I r ❑ Not in Comm./Govt. 0 Not in Comm./Other
; _Y_ __. - USDOT NO. ILCC NO. m
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' -n
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Black Blue
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Redmons/Owners Residence . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE