HomeMy WebLinkAbout2025-00032388 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ❑ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 ®NOT ON SCENE(DESK REPORT)
❑AMENDED ElB Injury and/or Tow Due To Crash YR 202512025-00032388 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
311 N SPRING ST Elgin 11:09
® ❑ RELATED 0 Y ®N 05 21 2025 DAM ❑YES ®NO U1 -<
_ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
_
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW Cl)
❑ FT/MI N E S W Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 NIA/ 0 icy ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
FOR DAMAGEDAREA(S) FRO TOWED U1 Q
NAME(LAST,FIRST,M) De La Rosa, Michael,0. m0 D 1 / /1 9 9 6 Chevrolet Camaro 2015 00-NONE tt_' Qr tf 0 ODE TO CRASH ❑ VI
13-UNDER CARRIAGE t9 i 2 FIRE 0NI
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 Ea U2 rn
M 9 SY4 ❑Y ®SNE❑UNK VEH. 0 AT CRAS IN H 0 15-OTHER
99-UNKNOWN 9 t6•TOP 3 `Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ ;i� a �i 4 COM VEH 0 Ea 1 00
~ ELGIN I L 60120 0 1 0 FIRST CONTACT 1 7 . __5 *Il Yes.See Sidebar U1
ZFG92466 IL 2025 Ismi
TELEPHONE
IL D 0 2G 1 FA1 E36F9117850 Amigo Insurance ❑Y Igl N U2 19 . m
5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
co
99 9 Same 12-2478612-00 2 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2
0 DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMV 0 NOV 0 DV
yr 12 _ C1
o 13-UNDER CARRIAGE 10 1 c. 2 FIRE ❑ ❑ U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 ❑ ❑ SPDR 0
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Ole/recto Value U1 9 -
POINT OF s-.;, 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT TA—" =5 COM•I sYEH See •Sidebar❑ 0
C
CO
F` pEAR` co
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O
❑Y ❑N RDEF73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
BAC
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
RESPElYO❑N NDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 0
W 1 2 /
DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 0 1 3 ComEd Comed Pole#432131348 05/21 /2025 11 09 ®pm in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
;, 2 0 36 3 1700 SPENCER RD Joliet IL 60403 28 20
t + / ❑PM• ❑Construction *
N 3 ® 31 3 igi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME
❑AM ❑Maintenance U2
-a, ARREST NAME De La Rosa, Michael,0. 11-601 449000393 / / El PM SLMT
o u 1 ❑ B!CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility
o N El AM 30
t 2 El ARREST NAME De La Rosa, Michael,0. 11-708 449000394 / / PM ❑Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y
2 3 ❑
449-Harris,Jacob 102 331-Ziegler 06 /09/2025 01 30 0 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
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
anriyr� - (example:shuttle or charter bus):or 0
3. Is designed to carry15 or fewer passengers and operated a contract carrier O
`'- -A----; Not To Scale `
( } } } transporting employee in the course of their employment(example:employee
1 cd,wuwd, transporter-usually a van type vehicle or passenger car):or w
4. Is used or designated to transport between 9 and 15 passengers,including rCjr
} } g po passen rs,includi the driver,
for direct compensation(example:large van used for specific purpose):or O
-� Orr r ��-��-----
i i. , 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). '0
unnr user
CARRIER NAME Z
ADDRESS 0
T.
Q N= CITY/STATE/ZIP C)
MOTOR CARR.ID 0 Interstate El Intrastate
0
1 I . 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
‘I. - --1 - USDOT NO. ILCC NO. m
73
Source of above z
. -I
Were HAZMAT placards on vehicle? 0 Yes 0 No =
If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. Xl
Xl
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's 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 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
co
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_COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Black
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U_DUE ETOO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO.DUE T VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE