HomeMy WebLinkAbout2025-00003002 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0038168,00
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INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 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 1
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 2025I 2025-00003002 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 mRAYMOND ST El 06:28
® ❑ RELATED ❑Y ®N 05 09 2025 12,— ❑YES ®NO U1 —<
_ _ g PRIVATE mo !day!yr ®PM FLOW CONDITION Ill
FT!MI N E S W PURIFY DR COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR IR SLOW 1 (n
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0
0 DRIVER ❑ PARSED ❑DRIVERLESS N PED ❑PEDAL ❑EWES ❑uuv ❑!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
FOR DAMAGEDAREA(S) FRONT TOWED U1 Rivero. Natalie. L. 1 0 /
yr 13-UNDER CARRIAGE 101 12! 2 FIRE 0
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STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
F 2 SY 15-OTHER
3 ❑Y ®SSE❑UNK VEH. O AT CRASH M IN D O 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 7 ij 6 4 COM VEH 0 j$J 1 0
~ Hanover Park IL 60133 B 1 0 FIRST CONTACT 00 7_; _-5 *uYes.SeeSidebar Ut
Z DU20313 IL 2025 E
TELEPHONE
IL D 0 1C4NJPFA6DD208376 NONE El ❑N U2 I''I
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
1 64 1 Same NONE 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER eM
Refused ❑Y ® N 2 0
N DRIVER ❑ PARKED ❑DRIVERLESS ❑ FED ❑PEDAL 0 EWES ❑!My 0 NCV 0 Dv
!1 9 yr 3 Toyota Sequoia 2016 00-NONE 11_"j Q�-_, DUE TO CRASH ❑ (� 2
0 13-UNDER CARRIAGE 10( I FIRE ❑ ® U2 C
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y NJ N DUNK VEH. AT CRASH 99-UNKNOWN *Oistrac Ion Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-it 6 �1:-4 COM VEH D ® U1 CO
FIRST CONTACT 00 7� .5 •(ryes.See Sidebar
= ELGIN
D IL 60124 0 1 0 DC30507 IL 2025 REAR
IL D 0 JTKJF5C75GJO26406 State Farm ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
64 1 Same 0384802-SFP-13 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
u 1 ® 12 1 05,09 /2025 06 28 ®AM in a Work Zone? ®N DIRP co
I I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
2 ❑ 99 99 05,09 ,2025 06 41 pM
1 ® • ❑Construction >F
Z 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
— N ®a ARREST NAME 05,09/2025 06 46 ®pM '
1 12 1 ElUtility
0 CITATIONS ISSUED ❑PENDING SLMT
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SECTION CITATION NO. ROAD CLEARANCE TIME 0 AM
T 2 0 ARREST NAME 05,09 ,2025 06 58 ®PM 0 Unknown work zone type U1 30
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ 1544-Solis,Yulissa 401 391-Jacobucci , ! 0 pM Workers present? ®N U2 30
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••--, , N A CMV is defined as any motor vehicle used to transport passengers or property and: Z
I i 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
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1 INDICATE NORTH combination):or p0
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ (example:shuttle or charter bus):or C
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A � C 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
ii } } } transporting employees in the course of their employment(example:employee X
b b transporter-usually a van type vehicle or passenger car):or w
L }-----}----; le Si'"a"r"" I. } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver. y
�_ for direct compensation(example:large van used fors cific purose):or O
L L____a_____ i• Vliti INN _ t i ii. , 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
IM placarding(example:placards will be displayed on the vehicle). ;p
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KM. CARRIER NAME Z
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, i.- MOTOR CARR.ID 0 Interstate 0 Intrastate
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1�, E USDOT NO. ILCC NO. m
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Source of above z
. Form Number
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IDOT PERMIT NO. WIDELOAD'; 0 Yes 0 No 2
TRAILER VIN 1 m
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LOCAL USE ONLY TRAILER VIN 2 m
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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 Red
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 0 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 0 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE