HomeMy WebLinkAbout2025-00034736 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X463838247-
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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 0$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00034736 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIPINTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 �I
BLUFF CITY BLVD Elgin12:33
0 0 RELATED ®Y ❑N 05 31 2025 12,-- ❑YES ®NO U1 -<
_ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION MFT!MI N E S W ST CHARLES ST COUNTY PROPERTY El ® N DOORING ID #OF MOTOR 0 SLOW 1 (/)❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑NIAV ❑Ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
T TOWED U1 Q
NAME(LAST,FIRST,M) mo
/1 9 9 8 General MotorSiQoq 2014 00-NONE ,, • 12 0DUE TOCRASH ❑ EN
13-UNDER CARRIAGE ! FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED 0 0 U2 4 M
F 9 SYTM
9 DY ❑SNE®UNK VEH. 9 ATCRASHD 9 99-UNKNOWN 9 76•TOP 3 ,Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s ;iI B �i 4 COM VEH 0 j$J 1 0
~ ELGIN I L 60120 0 9 0 FIRST CONTACT 1 7_; -_5 *II Yes.See Sidebar U1
Z3017714B IL 2025 REAR
TELEPHONE
IL D 3GTU2VECXEG206084 American Freedom Insuranc ❑Y ®N U2 1—
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Manzano-Garcia. Miguel.A. 12239832201 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER
/1 9 8 9 Chevrolet Trax 2024 oo-NONE 11_ 12 _, DUE TO CRASH ❑ 2 73
0 13-UNDER CARRIAGE 101 E FIRE 0 ® U2 C
c
M 2 4 SYSTEM IN 9 ENGAGED 9 15-OTHER O16.70P 3 X
❑Y ❑N ®UNK VEH. AT CRASH 99-UNKNOWN *Oistracuon Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF O I�!,_4 COM VEH ❑ ® Ut CO
F,,, FIRST CONTACT 7 Q._, _5 •IfYes.SeeSidebar C
ELGIN IL 60120 0 1 0 ES97595 IL 2025 I 0 Si)
M
IL D KL77LHE26RC224557 Kemper Insurance ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Arreguin-Arreguin. Maria.G. 12RA000041449 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE:ZIP 996 <
Refused RESPONDER
0 U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME(!{ADDRESS)!(TELEPHONE! (EMS) (HOSPITAL)
2 6 01 /
, D
/ / 4 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 05/31 /2025 12 33 ®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 C)
T
o� 2 0 2 04 / / 0 PN1 ❑Construction
1
Z3 0 1!>I CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 7
o1 ® 11 1 ARREST NAME Favela. Daniela. M. 11-709-A 483000344 / / El PM SLMT
o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility
El AM
t 2 El ARREST NAME 05/31 /2025 12 33 ®PM 0 Unknown work zone type U1 3O
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 30
483-Lynch, Miriam 400 07 /01 /2025 01 30 ®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
� l I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i. (example:shuttle or charter bus):or 0
' A 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
transporter-usually a van type vehicle or passenger car):or w
L L.___a._._� 4. Is used ordesi natedtotrans rtbetween9and15passengers,includingthedriver. C
- . g A } } } •
for direct compensation(example:large van used for speific purose):or 0
L .I. ioa. k_ } 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires, � O
-- j placarding(example:placards will be displayed on the vehicle). XI
—1
CARRIER NAME Z
ADDRESS
a.y.4T.
_ I L • Not To Scale CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
-----------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 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
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
White Black
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE