HomeMy WebLinkAbout2025-00028901 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
I0110110000011111 III 110 II
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003614178
u, 9 U21 1 1 1 U, 2 U299 U199 U299 U,99 U2 99 1 1 U123 U299 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ❑5501-51.500 ®ON SCENE 7
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) El B Injury and f or Tow Due To Crash
0 AMENDED YR 2025I 2025-00028901 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 m595 S STATE ST El In08:30
® ❑ RELATED ❑Y ®N 05 07 2025 ®AM El YES ®NO U1 -<
g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
_
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 99 Cl)
❑ FT/MI NESW 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
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 01 C)
FOR DAMAGEDAREA(S) FROhrr TOWED U1 Q
Martinez. Elsa.0. 1 2 /
yr 13-UNDER CARRIAGE NI
101 ! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® 0 U2 01 M
F 9 9 ❑Y ®SNEM❑ n is-OTHER
UNK VEH. AT CRASHIN n ENGAGED 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN x
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 2 it s ii,4 COM VEH ❑ Ig! 1 n
F.
ELGIN I N I L 60123 0 9 0 FIRST CONTACT 7 O7 :;L:Q-_5 *If Yes.See Sidebar U1 0
Z FA11601 IL 2025 REAR
TELEPHONE
IL D 0 5NMSH13E58H130236 Unknown El ID U2 M
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
1 54 5 Same Unknown 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ❑ N 2rg-
0
❑ DRIVER 0 PARKED 0 DRIVERLESS N PED 0 PED/L 0 EWES 0 MAV 0 NOV 0 DV
/1 9 6 4 Unknown Unknown 2016 00-NONE 1("j 12--_, DUE TO CRASH ❑ ® 99 x
0 13-UNDER CARRIAGE 10'( 2 FIRE ❑ ® U2 C
c IJ
F 1 3 SYSTEM IN 9 ENGAGED 9 15-OTHER 9,16-TOP 3 X
❑Y El ®UNK VEH. AT CRASH 99-UNKNOWN *Oistracton value g g
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s-it �1:-4 COMVEH ❑ ® U1 W
FIRST CONTACT 99 7 6 L,.5 •IfYes.See Sidebar
Z STREAMWOOD IL 60107 B 1 0 NA IL 2016 REAR
C
M
IL D 0 1 Unknown ❑Y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire 1 47 5 Same Unknown SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Provena St.Joseph RESPONDER U1 =
(UNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 12 5 05,07 ,2025 08 30 ®❑AM in a Work Zone? ®N DIRP co
1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1 C)
v 2 0 2 30 05,07 l2025 08 50 ❑pM 0 Construction *
R 3 0 gi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 99
z J ®AM ❑Maintenance U2
o 1 ® 12 5 ARREST NAME Martinez. Elsa.0. 11-1402-A 1543000174 05!07,2025 08 55 ❑pM El Utility SLMT
MI CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM
r 2 El ARREST NAME Martinez. Elsa.0. 11-1008 1543000175 05!07 l2025 08 30 MPM ElUnknown work zone type U1 05
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 - ❑AM Workers present? ❑Y 5
1543-Sturgeon. Kyle 701 ! / ❑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 -<
` ` --I -' r INDICATE NORTH combination):or —I
A BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} } I - } r r r (example:shuttle or charter bus):or 0
L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier O
J - ' I. } } transporting employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
� , C
I" --. t J } } } •f4.o Is used or designated to transport between 9 and 15 passengers,including the dryer. C
poY for direct compensation(example:large van used for specific purpose):or O
} } I _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
III
placarding(example:placards will be displayed on the vehicle). ,Zmt
CARRIER NAME Z
ADDRESS 0D
I Not To Scale w
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate ❑ Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
-----------1 - USDOT NO. ILCC NO. rn
Source of above z
. If Yes,Name on placard 0
4 digit UN NO. 1 digit Hazard class No. XI
XI
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's 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 ❑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 VIM 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' T
TRAILER 1 0 0 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Gray White
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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 9 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE