HomeMy WebLinkAbout2025-00035561 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
I0110110011 0
NO 11 11111
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00384O648
u, 1 U2 3 4 2 U1 4 U2 U, 1 U2 U, 1 U2 5 6 U1 3 U2 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY El 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 14
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
El AMENDED
YR 202512025-00035561 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
S MCLEAN BLVD El 00:20
® ❑ RELATED ®V 0 N 06 04 2025 ®AM ❑YES ®NO U1 -<
_ _ g PRIVATE mo !day!yr ❑PM FLOW CONDITION m
FT!MI N E S W LILLIAN ST COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR ❑SLOW Cl)
❑ Kane HIT ❑V ® N WITH VEHICLES INVLD El STOPPED U2 —I
® &RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUCE 0 uuv 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 00 n
FOR DAMAGEDAREA(S) FROf tf TOWED U1 Q
0 3
yr p tt. 12 Q
13-UNDER CARRIAGE 2 FIRE ❑ ®
16 O C
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 m
M 2 SYTM 4 ❑Y ®SNE DUNK VEH. 1 AT CRASH 0 15-99-UUNKNOWN THER9 t6•TOP 3 *Distraction Value ALGN
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r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6_iL 6 I, 4 COM VEH ❑ E! 1 0
~ ELGIN I N I L 60123 0 1 0 FIRST CONTACT 1 7_; __5 *II Yes.See Sidebar U1
Z EQ22472 IL 2026 REAR
TELEPHONE
IL D 7 J F1 G D29683G511964 Kemper Insurance ❑Y ®N U2 Mr-
Ill
5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 12au001574859 2 r
o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ❑ N 2
0 DRIVER 0 PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 nuy 0 i v 0 Dv
yr 12 _ X1
o 13-UNDER CARRIAGE 10 I 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 n
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction
value POINT OF3
s- , 4
AN CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POST CONTACT Y 6 I,_5 CIOMs gee Sidebar❑ 0 U1
CO
E REAR` CO
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O
❑Y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
BAC
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
RESPNDER❑YO❑N U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) n
/ / U2 r
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Pj
LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ❑ 1 5 06,04 ,2025 00 20 ®❑pM 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 �
57 2 ® 36 4 28 11
! ! ❑PM, ❑Construction *
t
Z 3 0 'xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2
-a, ARREST NAME Miranda Escobar. Hector 11-708 467-454 ! r El Pm SLMT
u1 ❑ BI CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM ❑Utility
t 2 El ARREST NAME Miranda Escobar. Hector 11-601-A 467-453 06!04 l2025 01 01 In PM ❑Unknown work zone type U1 35
n OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME ❑Y
❑AM Workers present?
2 3 ❑
467-Banks. Hannah 701 331-Ziegler 07 , 14/2025 01 30 ®PM I 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. INDICATE NORTH combination):or .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i I I I q - (example:shuttle or charter bus):or 0
I 8 r r r 3. Is designed tocarry15 fewer passengers and operated a contract carrier O` -A' I es or
.- s _ NbF7ti Sall i _ } } } transporting employees in the course of their employment� (example:employee � �
transporter-usually a van type vehicle or passenger car):or COL �.___a._._� O I —I 11 : i I 1 1 _ . 1 I 1 I 11 _ } 4. Is used or designated to transport between9and15passen passengers,1 I I N
f ( A for direct compensation(example:large van used for specific purpose):or O
.
L ____ ....1 71
unb.m - . l. L 1Is an 5. vehicleused to transport an hrdterial(HAZMAT)thatires
1 placarding(example:placards will be displayedazaous ma requ
on the vehicle). m
t
_ I CARRIER NAME Z
w I r' ADDRESS 0T.
CITY/STATE/ZIP C)
g
MOTOR CARR.ID 0 Interstate 0 Intrastate
1 I . 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
; _Y_ _.; - USDOT NO. ILCC NO. m
XI
Source of above z
. own tank)? 0 Yes 0 No 0 Unknown
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes ❑ 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
White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Adieu/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET
U_DUE ETOO T6 DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/
DUE T VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE