HomeMy WebLinkAbout2025-00032838 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 011011000 lOU 01100000
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003831428
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INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 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 ®ON SCENE 7
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00032838 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 71
811 E CHICAGO ST Elgin01:51
® ❑ RELATED ❑Y ®N 05 23 2025 ❑AM ❑YES El NO U1
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION MCOUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR ®SLOW 1 (n
❑ FT/MI NESW Cook HIT ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I
&RUN
O AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Q83 DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES p NW p!CV 0 DJ DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 n
/ ! FOR DAMAGEDAREA(S) FROPtf TOWED U1 Q
Unknown.O. Honda Civic 2007 00-NONE „ 12 , DUE TOCRASH ❑ EN
NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 10 !�. 2 FIRE 0
IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTEDU2 0 <
9 9 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 0 ' _
❑Y ®N ❑UNK VEH. ATCRASH 99-UNKNOWN `DistractionVatue ALGN
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~ 0 9 0 FIRST CONTACT 6 O7 ::L.Q_OS •lives.See Sidebar U1 0
Z FB40190 IL 2025 REAR
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1
2HGFG12647H530637 none ❑Y ❑N U2 I—
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 PACHECO VILLADA.ANGELICA. M. none 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
99 0
0 DRIVER X. PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 IIUV 0 NOV 0 DV
yr 10' 12 c, 2 FIRE 0 ® U2 2 C
o — 13-UNDER CARRIAGE
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
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❑Y El 0 UNK VEH. AT CRASH 99-UNKNOWN `Oistraci n Value U1 0
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N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6 COM VEH ❑ ® CO
F,,, FIRST CONTACT 6 O7 ,�=QI O6 •IfYes See Sidebar C
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M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
7SAXCAE51 NF346036 StateFarm ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 18 5 05,23 /2025 01 51 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 0 30 99
N 3 0 0 CITATIONS ISSUED 0 PENDING / / 0 PM- 0 Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 7
z
—a, ARREST NAME / / 0 PM '
1 ® 1 1 5 ❑CITATIONS ISSUED PENDING SLMT
o u SECTION CITATION NO. ROAD CLEARANCE TIME
ElUtilit y
r 2 El ARREST NAME 05!23 /2024 01 52 ®PM El Unknown work zone type U1 0 AM 10
n T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ ❑AM Workers present? ❑Y 1 O
1528-Rivera. Kevin 401 275-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 .Z-1
f BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
A _ } (example:shuttle or charter bus):or
X
I 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier O
I. } I- transporting employees in the course of their employment(example:employee °
""*u... transporter-usually a van type vehicle or passenger car):or C
L -----------; ` - I. } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver, N
for direct compensation(example:large van used for specific purpose):or O
t ii. , 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
! ,,,,,umpos placarding(example:placards will be displayed on the vehicle). XI
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CARRIER NAME Z
ADDRESS 'n
V)
•
TO Seale I CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
--- --1 - USDOT NO. ILCC NO. m
XI
Source of above z
Form Number m
Xl
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
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
Silver Red
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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE