HomeMy WebLinkAbout2025-00038124 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100001110111111111111
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0038550194
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 7
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 2025I 2025-00038124 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m822 SUMMIT ST Elgin01:24
® ❑ RELATED ❑Y ®N 06 15 2025 ❑AM ❑YES ®NO U1
_ _ PRIVATE mo /day/yr ®PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR IR SLOW 1 (n
❑ FT/MI N E S W Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 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 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
/ / FOR DAMAGEDAREA(S) FRONT TOWED U1 0
NAME(LAST,FIRST,M) Unknown.0. mo Jeep(after 19680nd Cherokee 2014 00-NONE ,,: -, DUE TO CRASH 0 13-UNDER CARRIAGE 10l 12 2 FIRE 0 IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED U2 0 <
9 9 SYSTEM IN
Y O ENGAGED 0 15-OTHER 9 16.TOP 3 ❑ _
❑ ®N ❑UNK VEH. AT CRASH 99-UNKNOWN $ 4 `Distraction Value 9 ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF II S li COM VEH ❑ j$J 1 O0
Z0 9 0 EC70221 I L FIRST CONTACT 6 T_:LQ-_s *uYes.See sidebar U1 0
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1)
1 C4RJFBG6EC534918 unknown ❑Y ❑N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Morales.Serafin.J. unknown 1 rn
`5 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
99 C)
g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 ivy 0 Ncv 0 DV
yr 10 I 12 c 2 FIRE 0 ® U2 C
Ti 13-UNDER CARRIAGE
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16•Tt)PE3� X
❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN Oistracton Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S-.l. 6 j( 4 COM VEH ❑ ® U1 CO
FIRST CONTACT 3 Y'_, _5 •• •IfYes,See SidebarC
H ELGINZ IL 60120 0 1 0 AK61975 IL 2025 I:EaR
M
IL D 1NXBR32E96Z573162 Erie Insurance ❑Y ®N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Gracia. Martin Q071816751 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
u1 =
(UNIT) (SEAT) (DO81 (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
2 3 04 / F 2 4 0 1 0
m
/ / #OCCS D
71
/ / U1 1 D
/ / 2 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 5 06 r 15 l2025 01 24 ®pm in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 0 30 18
N 3 0 ❑CITATIONS ISSUED 0 PENDING + ! ❑PM• ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM 0 Maintenance U2
-a, ARREST NAME ! / ❑PM
o u ® 11 5 0 •
CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT
10
r 2 ARREST NAME AM
7 r r ❑❑PM 0 Unknown work zone type U1
El
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ ❑AM Workers present? ❑Y 10
486-Munoz.Jasmine 200 407-Sproles r i ❑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 -<
` ` --1 -' r INDICATE NORTH combination):or .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
.Q. _ } (example:shuttle or charter bus):or 0
N "?1°"""°' 3. Is designed to carry 15 or fewer passengers and operated a contract carrier 0
I- l- -A- - i }} } transporting employees in the course of their employment(example:employee 73
transporter-usually a van type vehicle or passenger car):or w
L i.-----}----; I��II ♦ Scale - • } } } 4. Is used or designated to transport between 9 and 1 passen rs,including the driver. N
lY�i To 1 for direct compensation(example:large van used fors cific purpose):or 0
L i t i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). XI
—1
CARRIER NAME Z
_ ADDRESS D
i, iI ,.,1 w
CITY/STATE/ZIP 0
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
--- --1 - USDOT NO. ILCC NO. m
XI
Source of above z
. Form Number
m
Xl
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
v
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
Blue Silver
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE