HomeMy WebLinkAbout2025-00032568 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$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500
El NOT ON SCENE(DESK REPORT)
El AMENDED ElB Injury and for Tow Due To Crash YR 202512025-00032568 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �l
SLADE AVE Elgin01:18
® ❑ RELATED ®Y 0 N 05 22 2025 ❑AM ❑YES IX]NO U1
g PRIVATE mo /day/yr ®PM FLOW CONDITION Ill
FT l MI N E S W N SPRING ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR El SLOW 15 Co
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NW ❑ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
1 0 /
yr 11.. 12 0 DUE TO CRASH 0 E
13-UNDER CARRIAGE FIRE 0 (E
101 <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 2 DISTRACTED 0 0 U2 M
F 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 _
❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S_iL 6 I,,4 COM VEH 0 E! 1 0
~ ELGIN I L 60123 0 1 FIRST CONTACT 1 7_; __5 *II Yes.See Sidebar Ut
Z E943468 IL 2025 REAR
TELEPHONE
IL D 5NMSG13D29H251673 None ❑Y ®N U2 1--
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Olive'. Maria.C. None 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER
2 73
m g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑NMv 0 NCV ❑DV
/1 9 5 3 Nissan Altima 2021 00-NONE 'o,I t2 (,-2 FIRE DUE ID
CRASH 0 ® U2 2 C
o Yr 13-UNDER CARRIAGE
c
F 2 4 SYSTEM IN ENGAGED 15-OTHER 911,6•TOP 3 0 X
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistraglon Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 1 6 —4 COM VEH D ® Ut CO
FIRST CONTACT 5 O7 ,�=Q)OS •If Yes,See Sidebar C
ELGINZ IL 60120 0 1 4562244 IL 2025 ii 0 fp
D
IL D 1 N4BL4DVXMN366821 Amica ❑Y ®N RDEF M
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 95111221CY BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPOND 0 N U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 3 06 / F 1 3 0 1 U2 996 m
/ / ##occs >
/ / UI 2 D
/ / 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 4 05/22 /2025 01 18 ®AM in a Work Zone? ®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 7 n
T
0
2 ❑ 2 99 / / ❑PM• ❑Construction
1
R 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
-a, ARREST NAME Martinez Olivo. Brenda 11-901-A 414-1046 / / ❑PM SLMT
o u 1 ® 11 4 MI CITATIONS ISSUED 0 PENDINGTIME • ❑Utility
o NSECTION CITATION NO. ROADCLEARANCE AM
I 2 ❑ ARREST NAME Martinez Olivo. Brenda 3-707 414-1048 ! / 0 pM ❑Unknown work zone type U 30
1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑y 30
414-Lara. Saul 102 275-Engelke 06 / 16/2025 09 00 ❑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 La - I. combination):or —I Ju ' -IL
INDICATE NORTHBYARROW 2 Isusedordesignedtotransportmorethan 15 passengersincludingthedriver n_ (example:shuttle or charter bus):orNot To Scale I trans tl Rig em lloyeeo slin the courses 5 or fewer o ttheir emrs a lodym nt example:employee a contract ner} r } transppoorterg-usuallya van type vehicle or or CO
L L.__-a.. _ 4. Is used ordesi natedtotrans rtbetween9a d15rpassen rs,includingthedriver, C
I l' __) } } } for direct compensation(example:large van used for specific purpose):or O
L i — — Unit 1— — — t i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m placarding(example:placards will be displayed on the vehicle). XI
r - CARRIER NAME Z
ADDRESS 0
CCITY/STATE/ZIPOC
MOTOR CARR.ID 0 Interstate El Intrastate 5
I r1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
; _Y_._.. USDOT NO. ILCC NO. m
XI
Source of above z
'
. MCS 0 Yes 0 No 0 Unknown Out of Service 0 Yes ❑No 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 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Black Silver
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
_Redmons/Impound Lot Garage . 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/Unknown VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE