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HomeMy WebLinkAbout2025-00038296 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 011011000 l 111011110 * DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003659124 u, 1 U210 1 1 1 U111 U216 U, 1 1_12 1 U, 1 U2 1 1 9 U1 1 U221 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW ' Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ❑AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00038296 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n 3 CLOCK TOWER PLZ El In10:18 ® ❑ RELATED ❑Y ®N 06 16 2025 ®AM ❑YES ®NO U1 —< g PRIVATE mo /day/yr ❑PM FLOW CONDITION m _ COUNTY PROPERTY ®Y El N DOORING ❑y #OF MOTOR ❑SLOW 1 (n ❑ FT!MI N E S W Kane HIT&RUN ❑Y ® N WITH VEHICLESOT, INVLD ❑ STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ® FREE FLOW # LNS 0 Q83 DRIVER I] PARKED 0 DRIVERLESS 0 PED ❑PEDAL 0 EDUES 0 Nuv 0 ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 1 0 0 3 ! yr 13-UNDER CARRIAGE © IE 10,I !�. 2 FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 1 r<r1 F 2 SY 15-OTHER 4 ❑Y ®SNE DUNK VEH. O AT CRASH M IN D 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2 T CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 7 it B ii,4 COM VEH 0 j$J 1 0 ELGIN N I L 60120 0 1 0 FIRST CONTACT 11 7_:, __5 *llYes.See Sidebar U1 Z FD53356 IL 2026 REAR TELEPHONE IL Other 1 FMCU9GD9JUA53901 Safeway Insurance ❑Y ®N U2 13 . m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Mendoza-Rojas.Javier 3821093-IL-PP-005 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 73 ❑ DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMV 0 NOV 0 DV CIRCLE NUMBER(S) U1 yr 10) t2 , 2 FIRE ❑ ® U2 C 13-UNDER CARRIAGE v AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 ® SPDR n SEX SAFT AIR O 0 9!1,6•TOPO3 * 0 SYSTEM IN ENGAGED 15-OTHER a ❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN Oistraglon Value 9 0 POINT OF 8 4 Ut N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR S j',_ COM VEH ❑ jg C FIRST CONTACT 2 7_ • -5 •• •IfYes,See Sidebar H BZ37511 IL 2026 I 1 N M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 0 1 FADP3F2XEL153861 State Farm El ®N RDEF 7) EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Karen. Lantz. F. 0400525-SFP-13 BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = {UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)1ITELEPHONEI (EMS) (HOSPITAL) 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 18 5 06,16 /2025 10 18 ®❑AM in a Work Zone? ®N DIRP co 1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 � 2 ❑ 06 15 N 3 ❑ 0 CITATIONS ISSUED 0 PENDING + ❑PM• ❑Construction SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 —a, ARREST NAME / / El PM o N 1 ® 11 5 0 • CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT 10 T 2 ARREST NAME AM 7 1 r ❑❑PM ❑Unknown work zone type U1 El n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ 1540-Allah. Muhammad 401 407-Sproles , / ❑❑AM Workers present? ®N U2 10 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 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C - } (example:shuttle or charter bus):or X < ------;----; Parkin .lot 3. Is designed tocarry15 fewerpassengers andoperated carrier esg or by a contract ne i 0 g� ill; - } } } transporting employees in the course of their employment(example:employee X transporter-usually a van type vehicle or passenger car):or co L }---4----; - I. } } 1 •4. Is used or designated to transport between 9 and 15 passengers,including the driver, N for direct compensation(example:large van used for specific purpose):or O 2 L L } } 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m tplacarding(example:placards will be displayed on the vehicle). XI \ Z CARRIER NAME Z 1 I ADDRESS D nil 7 N w Not Tb Scale j CITY/STATE/ZIP n g MOTOR CARR.ID 0 Interstate 0 Intrastate 0 I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other ;------ --1 - USDOT NO. ILCC NO. m 73 Source of above z . Were HAZMAT placards on vehicle? 0 Yes 0 No = If Yes,Name on placard O 4 digit UN NO. 1 digit Hazard class No. XI XI Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's 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 i No 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 1-1 TRAILER 2 ❑ 0 0 o u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w White White 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