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HomeMy WebLinkAbout2025-00035736 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 0110110011011111111111011 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003846098 u, 1 U21 2 4 1 u, 2 U2 1 u, 1 1_12 1 u, 1 U2 1 4 15 u1 1 U2 1 *P 0119 INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A 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 Injury and/or Tow Due To Crash El AMENDED YR 2025I 2025-00035736 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1 COOPER AVE El In09:33 ® ❑ RELATED ®Y 0 N 06 04 2025 ❑AM ❑YES ®NO U1 -< _ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION m FT N E S W PRESTON AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OFMOTOR 0 SLOW 15 t� ❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!Cy 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C) FOR DAMAGEDAREA(S) FRO T TOWED U1 O Ocam o. Monika.Y. 1 2 / yr 13-UNDER CARRIAGE ©i 4 - FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O 2 DISTRACTED 0 0 U2 2 m F 2 8 SYTM❑Y ®SNE El UNK VEH. O AT CRASHO 0 99-UNKNOWN 15-OTHER 9 76•TOP 3 *Distraction Value ALGN X. T. CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF it 6 Ii 4 COM VEH 0 E! 1 0 F. ELGIN I L 60120 C 1 0 FIRST CONTACT 11 O7 _; __5 *II Yes.See Sidebar U1 O ZEH97648 IL 2025 REAR TELEPHONE IL D 0 2B3CL3CG1 BH537586 Kemper Insurance ❑Y Igl N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Elgin Fire Same 12RA000027265 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Sherman ❑Y ❑ N 2 XI p; DRIVER ❑ PARKED 0 DRIVERLESS ❑ FED 0 PEDAL 0 EWES 0!My ❑NCv ❑DV !2 0 0 0 Jeep(after 198;;i)ind Cherokee 2015 00-NONE 0.. QI'-O DUE TO CRASH rg 2 x o (3-UNDER CARRIAGE 10( I E FIRE 0 ® U2 C Ti F 2 8 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X ❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6-iI�1:,-4 COM VEH ❑ ® U1 co FIRST CONTACT 12 7�_1 s *If Yes.See Sidebar ELGIN IL 60120 C 1 0 EV98084 IL 2025 IL D 0 1 C4RJ FBG6FC922202 Progressive ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Elgin Fire Same 984212702 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Sherman RESPOND❑N u1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 1 3 01 / DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 11 4 Arzaluz. Edward.J. 15-20 ft of wooden fence 61 ,12 /25 09 38 ®AM 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 v 2 ❑ 653 COOPER AVE ELGIN IL 60120 23 15 / / 0 PM ❑Construction >F Z 3 ❑ El CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM Maintenance U2 ❑ o ® 11 4 ARREST NAME Ocampo, Monika,Y. 11-1204-B 469002436 / ! ❑PM SLMT o N 1 ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑El AM Utility r 2 ❑ 39 2 ARREST NAME 61 /12 /25 10 15 ElPM ❑Unknown work zone type U1 30 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 30 469-Taylor,Jonathan 201 331-Ziegler 71 , 12 /25 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 -< c ` -' -' r INDICATE NORTH combination):or —I p0 MY tp Scab, i BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver } (example:shuttle or charter bus):or C Li 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O I. } } transporting employees in the course of their employment(example:employee X L -----------; wWar+rw.nw •- 1 } } } transporter sed or des gnated to transport betweelly a van type vehicle or n 9 and passengers,15r including the driver, (C/) Lair $ N for direct compensation(example:large van used for specific purose):or O L L____a____� 5 t i i i t 5. Is any vehicle used to transport hazardous material(HAZMAT)thatrequires M any placarding(example:placards will be displayed on the vehicle). . 1 CARRIER NAME Z MAIM O ADDRESS CITY/STATE/ZIP C)0 Aven7 .5 MOTOR CARR.ID 0 Interstate 0 Intrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other -"--Y--'-1 - 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 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 to 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 Black 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 DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE