HomeMy WebLinkAbout2025-00031079 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111 III 11 III1II IIIIII U
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003623605
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INVESTIGATING AGENCY DAMAGE TO ANY El$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 14
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 2025I 2025-00031079 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
ROYAL BLVD El 12:07
® ❑ RELATED ®Y 0 N 05 16 2025 12,— ❑YES ®NO U1 -<
_ _ g PRIVATE mo r day/yr ®PM FLOW CONDITION Ill
FT N E S W N MCLEAN BLVD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR El SLOW 15 '
❑ Kane HIT ❑Y ® N WITH VEHICLES INVLD El STOPPED U2 —I
® &RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 KIN 0!CV ❑DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
0
FOR DAMAGEDAREA(S) FRONT TOWED U1 0NAME(LAST,FIRST,M) Ledesma Hernandez.Sandra mo yr Kia Motors Coo 2013 00-NONE DUE
Q �I 7T ❑
13-UNDER CARRIAGE DI E
10 1 2 FIRE 0 NI
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 0 m
F 2 4 SYTM❑Y ®SNE DUNK VEH. O AT CRASH 0 15-99-UNKNOWN THER9 16•TOP 3 `Distraction Value 9 ALGN
-
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�a �i 4 COM VEH 0 j$J 1 0
ELGIN I L 60120 B 1 0 FIRST CONTACT 11 7_: __5 *Ilyes.See Sidebar U1
Z FF86285 IL 2026 REAR
TELEPHONE
IL D 0 KNADM4A30D6225850 Progressive ❑Y Igl N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 99 9 Same 992670163 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused El ® N 2 0
p; DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 iiuv 0 i v ❑Dv
/1 9 9 9 Jeep(after 19681�rokee 2019 00-NONE 1("j t2..-_, DUE TO CRASH ❑ 2 x
0 13-UNDER CARRIAGE 10 i 2 FIRE ❑ ® U2 C
c
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 91 16-TOPO3 * X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN O Distraction Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-.I�I,4 COM VEH ❑ ® U1 CO
F,,, FIRST CONTACT 4 7�-_,SOS •byes,See Sidebar
ELGIN IL 60123 B 1 0 AR55886 IL 2026 BAR
C
M
IL D 0 1 C4PJMCB1 KD419308 State Farm ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire 99 9 Same 3364941-SFP-13 BAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Sherman RESPONDER u1 =
(UNIT) (SEAT) (DOE) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
1 3 05 / F 2 4 0 1 0
m
/ / #OCCS D
P7
/ / u1 2 m
/ / 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 4 5/ /6/ /025 12 07 ®PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
. 2 0 25 28 5/ /6/ /025 12 27 Pm® • ❑Construction >F
Z 3 0 ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM 0 Maintenance U2
-a ARREST NAME 5/ /6/ /025 12 28 ®PM '
,
I ® 11 4 ❑CITATIONS ISSUED ❑PENDING ElUtility
SLMT
o N SECTION CITATION NO. ROAD CLEARANCE TIME
0 AM
r 2 ElARREST NAME 5/ /6/ /025 01 05 ®PM ElUnknown work zone type U1 35
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ ❑AM Workers present? ❑Y 35
1 542 Chafe. Ethan 602 275-Engelke / ❑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 INDICATE NORTH combination):or -I
Ii BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ } (example:shuttle or charter bus):or
3. Is designed to carry15 or fewer passengers and operated a contract carrier O
ti - } } } transporting employee In the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
r K I ' - } } } 4. Is used or designated to transport between 9 and 15 passengers,including the driver, C
Not To Scale for direct compensation(example:large van used for specific purpose):or O
L L____a____. w _ l. l. l I t 5. Is any vehicle used to transport any hazardous material(HAZMAT)thatrequires
w: _ placarding(example:placards will be displayed on the vehicle). XI
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CARRIER NAME Z
111
Z
Z G'""'+F'r] ADDRESS D
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CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
----------1 - USDOT NO. ILCC NO. m
Xl
Source of above z
. IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No =
TRAILER VIN 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
v
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
Red Gray
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