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HomeMy WebLinkAbout2025-00031416 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 011011000 01011101 11111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003623434 u, 1 U21 1 1 1 U1 8 U2 1 U, 1 1_12 1 U, 1 U2 1 1 10 u1 3 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S 1215501-$1.500 El ON SCENE 3 VEHICLE/PROPERTY ❑OVER$1,500 ®NOT ON SCENE(DESK REPORT) El AMENDED ElB Injury and f or Tow Due To Crash YR 202512025-00031416 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n VILLA CT El In09:49 ® ❑ RELATED ®Y 0 N 05 17 2025 ❑AM ❑YES ®NO U1 -< _ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION m FT!MI N E S W D U PAG E ST COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR ❑SLOW 1 U.)❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑uuv ❑ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n 0 2 FOR DAMAGEDAREA(S) FRONT TOWED U1 Q NAME(LAST,FIRST,M) Moreta Palacios.Silvia. L. mo Nissan Sentra 2012 00-NONE DUE TOCRASH ❑ EN O! yr ©1 12 13-UNDER CARRIAGE 9 I I! 2- FIRE 0 IE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m F 2 SY4 ❑Y ❑SNE®UNK VEH. 9 AT CRASIN H 9 99-UNKNOWN 9 16•TOP 3 `Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, ii_6 1i 4 COM VEH ❑ E! 1 0 F. Hanover Park IL 60133 0 1 0 FIRST CONTACT 11 7_; __-5 *IIVes.See Sidebar U1 ZEZ19232 IL 2025 REAR TELEPHONE IL D 0 3N1AB6APXCL739691 Progressive ®Y ❑N U2 I— in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR M Same 988932566 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ® N 2 XI N DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES O uv 0 KCv ❑Dv !1 9 8 7 Jeep(after 196g)ind Cherokee 2015 00-NONE 11"j 12--_, DUETO CRASH ❑ 2 x o 13-UNDER CARRIAGE 'IFIRE ❑ ® U2 c M 2 4 SYSTEM IN 9 ENGAGED 9 15-OTHER 9 16.TOPO3 * X ❑Y ❑N ®UNK VEH. AT CRASH 99-UNKNOWN O Oistraellon Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-iI 6 �. 4 COM VEH ❑ ® U1 CO F,,, FIRST CONTACT 2 7�. _�-_®•If Yes,See Sidebar ELGIN IL 60123 0 1 0 DP42214 IL 2025 REAR 0 IL D 1 C4RJ FCT3FC769144 State Farm ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Quevedo.Ana. B. 2449987sfp13 SAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (0081 (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) U2 996 r m ##occs y 71 / U1 1 D 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 1 05,17 /2025 09 49 ®PM 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 o" 2 06 99 ) / ❑PM ❑Construction * R 3 0 $I CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM 0 Maintenance U2 o1 ® 11 1 ARREST NAME Moreta Palacios.Silvia. L. 11-708 S1522-307 ! ! El PM SLMT o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility 30 T 2 ARREST NAME AM 7 , , ❑❑PM 0 Unknown work zone type Ut El n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 1522-Velazquez. Noeli 101 331-Ziegler , / ❑❑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••--, , ; 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 -< ` ` -'- ' r INDICATE NORTH combination):or —I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver n I I - } (example:shuttle or charter bus):or C 3. Is designed to carry 15 or fewer and operated by a contract carrier O i. }_--------•i I } } } 3.transporting employees In the course of their passengers and operated r (example:employee s transporter-usually a van Type vehicle or passenger car):or ' • . 4. Is used or designated to transport between 9 and 15 passengers,including rCjt CO }--- ----+ I - } } } g po passen rs,includi the driver, umwrx, wumn for direct compensation(example:large van used for specific purpose):or O L L____a____. _ _ _ _ . - - - - - _ L i I 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m is placarding placarding(example:placards will be displayed on the vehicle). ;p I I* ,L ,L , CARRIER NAME Z I I ADDRESS O I I T. Not m Scab I I l 0 is CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate El Intrastate 1 I r 1 ❑ 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 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 - 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 VIM 1 m co LOCAL USE ONLY TRAILER VIN 2 m v TRAILER WIDTH(S) 0-96" 97-102" >102' m TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 ❑ O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Black Black u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO: _ . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO. DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE