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HomeMy WebLinkAbout2025-00029565 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 011011000 l 0I 1 110 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003813581 u, 1 U21 1 1 1 U199 U2 1 U, 1 1_12 1 U, 1 U2 1 4 11 u, 2 u2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash El AMENDED YR 202512025-00029565 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 m® ❑ RELATED PRIVATE ❑Y ®N 05 09 2025 12,—AM ❑YES El NO U1 -< S RANDALL RD Elgin mo /day/yr 1122 ®PM FLOW CONDITION MI_ 25COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 2 fA ® FT 1� N E OS Vtr South St WITH VEHICLESOT, INVLD ❑ STOPPED U2 —I 0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑V ® N PEDALCYCLIST®N ® FREE FLOW # LNS 0 183 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 NW 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n 0 6 / yr 13-UNDER CARRIAGE ©,I 0,,:0 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 rn M 2 SY5 ❑Y ®SNE DUNK VEH. O AT CRASH M IN D O 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�6 4 COM VEH 0 Ea 1 0 F. Hanover Park IL 60133 0 1 0 FIRST CONTACT 12 7_: __5 *uves.SeeSidebar Ut Z 3498519B IL 2025 REAR TELEPHONE IL D 3TMCZ5AN3GMO43202 STATE FARM ❑Y ®N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same 0300211-SEP-13 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y El 2 0 N DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 lily 0 i v 0 Dv /1 9 6 9 Dodge Ram 1500(pickup) 2007 00-NONE ,t-1 12--_, DUE TO CRASH ❑ C 2 o iS-UNDER CARRIAGE 10;1 2 FIRE ❑ ® U2 C Ti M 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP 3 X 0 Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istracl n Value 9 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 i 6 ....4 COM VEH ❑ ® U1 CO F,,, FIRST CONTACT 5 7 -�'OS •(ryes,See Sidebar C ELGIN Z IL 60123 0 1 0 1750229B IL 2025 REAR 0 N M IL D 1 D7H U 18297J523532 AM ICA ❑Y 123 N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same 91111220BU BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 < Refused RESPONDER U1 = (UNIT) (SEAT) (D081 (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)1(TELEPHONE) (EMS) (HOSPITAL) W 1 0 / m / / #OCCS D 71 / / U1 1 D / / 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 05,10 /2025 11 22 ®pM 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 ;, 2 0 1 3 28 18 / 1 ❑PM• ❑Construction >E R 3 0 $I CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM 0 Maintenance U2 o ® 11 1 ARREST NAME Morales Martinez. Miguel.A. 11-601-Ax 1517000436 / / ❑PM SLMT o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' El Utility 45 T 2 ARREST NAME AM T El / / ❑❑PM 0 Unknown work zone type U1 n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIMED 2 2 3 0 1517-Le Cates. Brittany 702 331-Ziegler / / ❑❑PM Am Workers present? ®N U2 45 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 -< ' }--_.r-_' j } combination):or —I INDICATE NORTH p1 t, 801°°'�'�^ t BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C - (example:shuttle or charter bus):or n - - - - - 3. Is designed to carry15 or fewer passengers and operated by a contract carrier I O }----------J. I - } } } transporting employees in the course of their employment(example:employee X y a van type L •L.___a____. transporter sed ord�ll designated to transehrt betweeicle or n 15r) ssen rs,including the driver. C 1 i } } } for direct compensation(examp large van used for specific purpose):or; ; ne�mm.,syn____ l. I I 5. Is any vehicle used to transport anyhazardous material(HAZMAT)thatrequires rn placarding(example:placards will be displayed on the vehicle). ;p CARRIER NAME Z - ADDRESS 'n Not To Scale 1 W CCITY/STATE/ZIPng MOTOR CARR.ID 0 Interstate 0 Intrastate 1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other -"---- --1 - USDOT NO. ILCC NO. rn XI Source of above z . Form Number 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' m TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 ❑ O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Red Black u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. _Adieu/Impound Lot Garage . 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