HomeMy WebLinkAbout2025-00037142 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
I011011000011I II III IIIIII
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003849992
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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$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 2025I 2025-00037142 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I
® ❑ RELATED ❑Y ®N 06 11 2025 IgiAM D YES ®NO U1 -<
MARKET ST Elgin09:10
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FT!MI N E S W LARKIN AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW Cl)
❑ Kane HIT&RUN ❑V ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 —I
Igl AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
f'rf TOWED U1 Q
Nissan Murano
NAME(LAST,FIRST,M) Flores. Leticia.T. mo yr 00-NONE 2009 1 DUE TOCRASH ❑,t. 1z Q VI E
13-UNDER CARRIAGE 101 z FIRE ❑ NI
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ ga U2 m
F 2 4 ❑Y ® is-OTHER
SYSTEM
❑UNK VEH. 0 AT CRASHD 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 iL a �i COM VEH 0 j$J 4 0
~ ELGIN I L 60123 0 1 0 FIRST CONTACT 1 7 ; __5 *IIYes.See Sidebar U1
Z DQ90195 IL 2025 REAR
TELEPHONE
IL D JN8AZ18W49W214433 Direct Auto Ins Co ❑Y J N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
47 1 Same PAIL001030023 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 2 0
0 DRIVER ❑ PARKED 0 DRIVERLESS N PED 0 PEDAL 0 EWES 0 NuV 0 NOV 0 DV
yr 1 j t2 c, 2 FIRE ❑ ® U2 C
o 13-UNDER CARRIAGE
c
F Y SYSTEM IN ENGAGED 15-OTHER 911,6•TOP 3
❑ ❑ ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8- I -4 COM VEH ❑ NI U1 CO
FIRST CONTACT OO 7��. �.5 •(ryes,See Sidebar C
H ELGINZ IL 60123 B 1 0AR
0 Si)
M
IL ❑Y ❑N RDEF73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire 1 47 1 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Provena St.Joseph D Y°®N u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
0
EV MOST EVNT LOS DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 12 1 06/11 /2025 09 10 ®❑AM in a Work Zone? ®N DIRP co
I I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1 C)
v 2 28 99 06,11 /2025 09 11 ❑PM ❑Construction >F
R 3 ❑ ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME
z J ®AM ❑Maintenance U2
o ® 12 1 ARREST NAME Flores. Leticia.T. 11-601 481000251 06/11 /2025 09 16 ❑PM SLMT
o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
AM U1 30
T 2 El ARREST NAME 06/11 /2025 09 30 [0 PM El Unknown work zone type
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? D Y
481-Rodriguez. Hannah 602 275-Engelke 07 , 15/2025 01 30 0 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 -<
` ` -' -n r INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
1 _ } (example:shuttle or charter bus):or
Not To ScaleX
L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
--'•-•... A. - } } } transporting employees In the course of their employment(example:employee X
lly a van type vehicle or
L ______----; 'ruffs \ N - . } } } •transporter. sed or des gnated to transport between 9 and 15 passengers,including the driver.enger car):or c0
for direct compensation(example:large van used fors specific purose):or
kMrk�t?et > Unit t
L L____a____. " _ i i 5. Is any vehicle used to transport anyhazardous material(HAZMAT)thatrequires
1:1
r# placarding(example:placards will be displayed on the vehicle). �
4+
\ _ CARRIER NAME Z
0
eeoar.erlmwn ADDRESS
w C
CITY/STATE/ZIP 00
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 ❑ 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
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 0 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO.
DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE