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HomeMy WebLinkAbout2025-00034924 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 0110110011 Mfl IEl Oil DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV XDD3839503 u, 1 U21 1 1 1 U116 U2 7 U, 1 u2 1 U, 1 U2 1 1 11 U1 1 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) (8:1B Injury and/or Tow Due To Crash 0 AMENDED YR 202512025-00034924 VENT ADDRESS NO. HIGHWAY or STREET NAME El ❑CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 m RT20 RELATED ❑Y ®N 06 01 2025 05:25 ®AM ❑YES ®NO U1 -< Elgin PRIVATE mo /day/yr ❑PM FLOW CONDITION m E05 ®0 !MI N E s w Longcommon Pk COUNTY PROPERTY ❑Y ® N DOORING ❑Y #OF MOTOR 0 SLOW 15 u) g Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ® FREE FLOW # LNS O 18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 NOV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 FOR DAMAGEDAREA(S) FROf'1T TOWED U1 0 Servin Ayala. Moises 0 3 / yr 13-UNDER CARRIAGE ©I O; 0 FIRE 0 NI STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED 0 0 U2 4 R<7 M 2 SY4 ❑Y ❑SNEM®UNK VEH. 9 AT CRASH IN 9 15-OTHER 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s I,I,.4 COM VEH ❑ Ea 1 0 ~ ELGIN I L 60120 0 1 0 FIRST CONTACT 12 7_: __5 *Yves.See Sidebar U1 Z 3122305B IL 2025 REAR TELEPHONE IL D 1 FTFW1 EF8BFD05662 Kemper Insurance ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same 12RA000018458 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ® N 2 XI m x DRIVER ❑ PARKED 0 DRIVERLESS ❑ FED CI PEON. ❑EWES ❑NMV 0 NCv ❑DV � !1 9 6 2 Mitsubishi Endeavor 2005 00-NONE 11 `'OI'0 DUE TO CRASH rg ❑ 2 x 0 13-UNDER CARRIAGE i,, FIRE ❑ ® U2 II M 2 4 SYSTEM IN 9 ENGAGED 9 15-OTHER O9 16-TOP 3 X ❑Y ❑N ®UNK VEH. AT CRASH 99-UNKNOWN *0istraglon VaIue 9 U1 9 POINT OF s I 4 COM VEH ❑ ® CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 12 Yjd_d =5 •Iryes,See Sidebar C — Hampshire IL 60140 0 1 0 EW81044 IL 2025 I 9 N IL D 4A4M N31 S55E013799 State Farm ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same 1794214SFP13 BAC $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPOND O N U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 22 3 I DOT Concrete RailiConstructio 06,01 ,2025 05 25 P123AM in a work zone? ®N DIRP co 1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 0 ;, 2 ❑ 925 DUNDEE AVE ELGIN IL 60120 03 03 ( / PM ❑ , ❑Construction * Z 3 0 El CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM ❑Maintenance U2 o 1 ❑ 11 1 ARREST NAME Servin Ayala. Moises 11-709-A W483000343 ( ! El PM SLMT BI CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM- ❑Utility Ti 2 ® 22 3 ARREST NAME Walsh.John. M. 11-710-A W483000342 06(01 (2025 06 00 j PM ❑Unknown work zone type U10 50 2 2 3 0 OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 50 483-Lynch, Miriam 800 331-Ziegler 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 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C _ } (example:shuttle or charter bus):or X 3. Is designed to}- -- i carry15 or fewer passengers and operated I a contract carrier O --- ---- } } 1. transporting employee � �In the course of their employment(example:employee � T L �° transporter-usually a van type vehicle or passenger car):or w L L.___a____.l J t 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including C } } for direct com nation exam I lar a van used for s cific ur o ):or the driver, Pe ( P 9 Pe P Pose):or L L____a____. U2— U1 — r -Vr_"`,5 i i L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m /1.4*— +'— ;yya; 7 placardingX/ (example:placards will be displayed on the vehicle). T ►offD A CARRIER NAME Z ADDRESS 0 N w Lonpcomrnon?Pkwy CITY/STATE/ZIP g Not To Sca - MOTOR CARR.ID 0 Interstate 0 Intrastate 1 I r bs 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other ;_...Y. ._.; - USDOT NO. ILCC NO. m XI Source of above z . MCS ❑Yes 0 No 0 Unknown Out of Service ❑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 0 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Gray Silver u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. Arties/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® Arties/Impound.Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE