HomeMy WebLinkAbout2025-00031147 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003623704
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 2025I 2025-00031147 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 -n
SUMMIT ST Elgin 04:37
® ❑ RELATED ®Y 0 N 05 16 2025 ❑AM ❑YES N NO U1 -<
g PRIVATE mo !day!yr ®PM FLOW CONDITION ITl
_
FT!MI N E S W PORTER CT COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR IR SLOW 1 (/)❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0
/83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑uuv 0!Cy ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0
0 7 !
yr 13-UNDER CARRIAGE I ! FIRE ❑ N
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 4 (<Tl
M 2 SY4 ❑Y ❑SNEM®UNK VEH. 9 AT CRASH IN 9 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, it 6 �i COM VEH 0 j$J 1 0
ELGIN IL 60120 0 1 0 FIRST CONTACT 11 7_;1 __5 *II Yes.See Sidebar U1
Z EP45655 IL 2024 REAR
TELEPHONE
IL D 0 2HGFE2F5XRH557681 Allstate ❑Y ®N U2 I'
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 975561307 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y ® N 99 CAi
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m x DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑iiuv 0 Ncv ❑Dv
!1 9 8 8 Toyota Camry 2015 00-NONE 11_"1 QI O DUE TO CRASH rg ❑ 2
o r 13-UNDER CARRIAGE 10( ) 2 FIRE ID N U2 C
M 2 4 SYSTEM IN 9 ENGAGED 9 15-OTHER 9 1,6-TOP 3 X
❑Y ❑N N UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-it 6 1l, COM VEH 0 N U1 CO
FIRST CONTACT 1 Y _, _5 •(ryes,See Sidebar
= ELGINREAR
IL D 0 4T1 BF1 FKOFU961376 Geico ❑Y N N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 6120689077 BAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) ISEATI (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
2 4 09 / F 2 4 0 1 U2 996 m
/ / #OCCS >
71
/ / U1 1 D
/ / 2 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
u 1 ® 11 1 05,16 l2025 04 37 0 AM in a Work Zone? NCI N DIRP co
1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 1 n
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2 ❑ 2 18 I ! ❑PM• ❑Construction X
R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM ❑Maintenance U2
a1 ® 11 1 ARREST NAME Sanchez.Alex 11-901 W1539000190 / ! ❑PM SLMT
o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' ❑Utility
35
r 2 ARREST NAME AM
T 1 r ❑❑PM 0 Unknown work zone type U1
El
OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 35
1539-Vargas. Miguel 201 - 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 -<
c ` --I -' r INDICATE NORTH combination):or .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ } (example:shuttle or charter bus):or
X
3. Is designed to carry 15 or fewer passengers and operated a contract carrier O
- -----------J. ` }} } transporting employees in the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or CO
L L.___a____.I
I. }- 4. Is used ordesi natedtotrans rtbetween9and15passengers,includingthedriver. C
} for direct compensation(exam :large van used for speific purose):or (I)eunmrree47% + O
__ pt i. < i. 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). ,Zmt
ao�✓a Not To Scale I ® CARRIER NAME Z
ADDRESS 0
C)
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
----'Y----1 - USDOT NO. ILCC NO. rn
XI
Source of above z
. own tank)? 0 Yes 0 No 0 UnknownT.
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
to
LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Blue 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 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Other t Owners Residence VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE