HomeMy WebLinkAbout2025-00031207 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Df 2 Sheets _ 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0036238.66
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) 0 B Injury and f or Tow Due To Crash
El AMENDED
YR 2025I 2025-00031207 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 71
® ❑ RELATED ❑Y ®N 05 16 2025 ❑AM ❑YES ®
PRIVATE NO U1
S STATE ST Elgin mo /day/yr 09:28 ®PM FLOW CONDITION M
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 cn
020 ®!MI N E OS VY Route 20 WITH VEHICLESOT,
INVLD ® STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN IZ Y ❑ N PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
(g:DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2
FOR DAMAGEDAREA(S) FIX)Ni TOWED U1 0
NAME(LAST,FIRST,M) Unknown. Unknown.O. mo r
13-UNDER CARRIAGE 10 , 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
9 9 ❑Y ®SNEM❑UNK VEH. 0 AT CRASH IN ENGAGE0 99-UUNKNOWN 9 16-TOP 3 ,Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 iI 6 4 COM VEH 0 j$J 1 0
~ Unknown 0 9 0 FIRST CONTACT 12 7 ;1 _5 *u Yes.See Sidebar Ut
ZET94431 IL 2025
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1/
1 FMCUOGX6DUD56824 StIL' ate Farm ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Lazalde.Cristina. M. 1654969-SFP-13 1 rn
`5 HOSPITAL(TAKEN TO) INCIDENT IF'Y OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
99 GC)
N DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑NMV 0 NOV ❑DV
/2 0 0 7 Lincoln M KC 2017 oo-NONE 1("j 12..-_1 DUE TO CRASH ❑ 2 x
o -y Yr 13-UNDER CARRIAGE 10'I c. 2 FIRE ❑ ® U2 C
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X
❑Y Ig N ❑UNK VEH. AT CRASH 99-UNKNOWN *OistractIon Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 i 6 i.,, COM VEH ❑ ® U1 CO
FIRST CONTACT 7 O7 _� -5 •If Yes.See Sidebar C
ELGIN IL 60120 0 1 0 AY39908 IL R 0 Si)
IL D 0 SLMCJ3C93HUL16351 Selective Insruance ❑Y ®N RDEF P3
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 X
99 9 Miller. Mark S2618638 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
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DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 1 I DOT Guard Rail 05,16 /2025 09 29 ®AM 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 9759 IL ROUTE 76 BelviderelL 61008 06 99 r , ❑PM ❑Construction
Z3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 1
-a, ARREST NAME / / El PM '
o N ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
SLMT
t 2 ❑ 45
AM
T ❑PM 0 work zone type U1
ARREST NAME 1 / ❑
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 El Workers present? 0 Y 45
1524 Silva Jose 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 truck trailer -<
} } ' ' I I. INDICATE NORTH combination)or
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BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- (example:shuttle or charter bus):or
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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 X
transporter-usually a van type vehicle or passenger car):or w
L L.___a._._. I.
} I 1 4. Is used ordesi natedtotrans rtbetween9and15passengers,includingthedriver, N
} for direct compensation(example:large van used for speific purose):or
rsout4372e ra �"o,, of - 4. } } t 5. is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle).
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!"r CARRIER NAME
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/ ADDRESS 0
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CITY/STATE/ZIP
- MOTOR CARR.ID El Interstate El Intrastate
Not To Scale e9 ''�` O
.I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
‘I. - --1 USDOT NO. ILCC NO. m
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Source of above z
. MCS 0 Yes 0 No 0 Unknown Out of Service 0 Yes ❑No Z
Form Number 0
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IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
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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
White Blue
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Mies/Impound Lot Garage . 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