HomeMy WebLinkAbout2025-00029335 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111 011011000 l II 0 DI 110
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and/or Tow Due To Crash YR 2025I 2025-00029335 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 71
S MCLEAN BLVD Elgin11:09
® ❑ RELATED ❑Y ®N 05 08 2025 ❑AM ❑YES IX]NO U1 -<
_ _ PRIVATE mo !day/yr ®PM FLOW CONDITION MFT!MI N E S W LILLIANST COUNTY PROPERTY El ® N DOORING Ely #OF MOTOR 0 SLOW 1 fu7
❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0 Icy ❑ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) y N 6 0
/ ! FOR DAMAGEDAREA(S) FROM TOWED U1 f'
Kia Motors Co rento 2011 00-NONE ,, DUE TO CRASH 0 NAME(LAST,FIRST,M) Unknown.0. mo yr0
13-UNDER CARRIAGE 12! FIRE 0 IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) �� O
9 9 SYSTEM IN O ENGAGED 0 15-OTHER 976.70P�3 DISTRACTED 0 ]$I U2 6
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN Distraction Value 9 ALGN
T. CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6• iI 6 it,C.OM VEH 0 j$J 1 n
F_ FIRST CONTACT 3 7__1�__;_O6 •If Yes.See&debar U1 0
2 Z
0 9 0 CX11482 IL 2024 REAR
_ -I TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1)
SXYKT3A13BG065625 NIA ®Y 0 N U2 I—
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Lauderdale.April NIA 1 rn
`5 HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
99 C)
x DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED CI REM 0 EWES ❑ uv 0 NOV ❑Dv
!2 0 0 4 Acura Integra 2025 00-NONE „ ` 12' _, DUE TO CRASH ❑ 2 73
o _ 13-UNDER CARRIAGE FIRE ❑ ® U2
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 016-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistractlon Value 9 g
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF O I i 4 COM VEH ❑ ® O1 COF,,, FIRST CONTACT 9 O7 j_,,_s •It Yes.See Sidebar C
ELGIN IL 60123 0 1 0 FD51521 IL 2026 REARN
IL D 19UDE4H23SA011900 Progressive Insurance ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Vega.Jennifer 995519009 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
u1 =
(UNIT) (SEAT) (D081 (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)!(TELEPHONE! (EMS) (HOSPITAL)
2 3 02 /
2 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 05 108 /2025 11 09 ®AM 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 04 06
N 3 ❑ 0 CITATIONS ISSUED CI PENDING + ! 0 PM• El Construction
SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
z
-a, ARREST NAME / / El PM '
S' N 1 ® 11 1 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility
SLMT
30
t 2 ARREST NAME AM
1 r ❑❑PM 0 Unknown work zone type U1
El
7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 - ❑AM Workers present? ❑Y 30
1550-Camiacho.Oscar 701 r ! ❑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 -<
i- }____r____; I I I INDICATE NORTH combination):or —I
p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} N I I 1 I _ } (example:shuttle or charter bus):or C)
J r r r X
3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
} } } transporting employees in the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or CO
L L.__-a-_- N 4. Is used ordesi natedtotrans rtbetween9and15passengers,includingthedriver,
I I �I I. } for direct compensation(example:large van used for speific purose):or 0
L L____a..... L i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D
N placarding(example:placards will be displayed on the vehicle). M
0
EL. y 2#
CARRIER NAME
I ADDRESS 0
I I I to
s C)
telvd CITY/STATE/ZIP
Not To Scale I 1 MOTOR CARR.ID 0 Interstate 0 Intrastate
1 I r 1 ❑ Not in Comm./Govt. Not in Comm./Other
. . . . ❑
r ;____Y___ 1 - USDOT NO. ILCC NO. m
XI
Source of above z
—I
Were HAZMAT placards on vehicle? 0 Yes 0 No =
If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. Xl
Xl
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 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
Silver 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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE