HomeMy WebLinkAbout2025-00036615 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 4 Sheets MI1111111111111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X0038-50001
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INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED YR 202512025-00036615 VEHT
ADDRESS NO. HIGHWAY or STREET NAME El ❑CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 �l
RT20 RELATED ®Y 0 N 06 08 2025 09:20 ❑AM ❑YES El NO U1
Elgin PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT N E S W LONGCOMMON PKWY COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N 51 FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0
0 4 /
yr 11-_ 12 -
13-UNDER CARRIAGE 10l • 2 FIRE ❑ al
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 4 M
M 2 8 El ®SNE❑UNK VINEH. ATCRASHD 99-UUNKNOWN 9 16•TDP�3 `DistractionValue ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8• iI 6 I.I.®COM VEH 0 Ea 1 C)
F. FIRST CONTACT 4 7 _1,--:;_O 'IrVes.SeeSidebar U1 0
Z Carpentersville IL 60110 0 1 0 3453636E IL 2025 REAR
TELEPHONE
IL D 0 1GCCS1441X8161382 Progressive ❑v ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Avila Ramirez. Diana.A. 991027290 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 XI
x DRIVER 0 PARKED 0 DRIVERLESS ❑ FED 0 PEDAL 0 EWES 0 NMv 0 KDV 0 DV
/2 0 0 3 BMW 540 1999 00-NONE O-i Q!'-O, DUE TO CRASH 0 p 2 x
0 13-UNDER CARRIAGE 10( I 2 FIRE ❑ El U2 C
M 2 8 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `OistracI n Value 0
POINT OF 8 i1 A -4 COM VEH ❑ ® U1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 12 7� B .6 •(ryes,See Sidebar
n BARTLETT IL 60103 0 1 0 CU62414 IL 2022 REAR 0 C
IL D 0 WBADN533XXGC91873 Geico ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 X
99 9 Same 6002633144 BAc E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)/(TELEPHONEI (EMS) (HOSPITAL)
1 3 06 / F 2 5 B 1 0
m
/ / #OCCS >
71
/ / UI 2 D
/ / 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ®Y U2 Z
N 1 ® 11 1 06/08 /2025 09 20 0 AM in a Work Zone? ❑N DIRP co
1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
v 2 ❑ 2 99 O6/08 /2025 09 20 ®PM ®Construction >E
<w 3 0 ]$I CITATIONS ISSUED PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
z J ❑AM 0 Maintenance U2
o ® 11 1 ARREST NAME Martinez.Jeovanny 11-901-A 1515-000686 06/08/2025 09 22 Igi PM SLMT
o N -
❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' ❑Utility
0 AM
r 2 0 ARREST NAME 06/08 /2025 10 00 0 PM El Unknown work zone type U1 45
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 45
1515-BellEck.Stacy 801 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 A 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
} } ' ' r INDICATE NORTH combination):or
N BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
Not To Scale - (example:shuttle or charter bus):or 0
< <---- ----; ti } } } transporting employeesned to Inthe course passengers or fewer thir emplod yment example:employeerier X
transporter-usually a van type vehicle or passenger car):or w
L L.___a____� 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including C
} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or
L a----. - i. < i. L 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
2 a,%=.. t placarding(example:placards will be isplayed on the vehicle). D
Il:vi�] I _� 1 *I —I
CARRIER NAME Z
' „ �/ __ ADDRESS D
ler ® 0
CITY/STATE/ZIP n
g
- MOTOR CARR.ID 0 Interstate 0 Intrastate
I . ❑ Not in Comm./Govt. 0 Not in Comm./Other
--- --1 USDOT NO. ILCC NO. m
XI
Source of above z
. IDOT PERMIT NO. WIDELOADo ❑Yes 0 No =
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 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