HomeMy WebLinkAbout2025-00039499 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003662021
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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-$1.500 ®ON SCENE 16
VEHICLE/PROPERTY ❑OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00039499 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 mRT20 EB EXIT RAMP El In 07:56
® ❑ RELATED ®Y 0 N 06 20 2025 ❑AM ❑YES ®NO U1 -<
g PRIVATE mo /day/yr ®PM FLOW CONDITION IT1
FT!MI N E S W RTZO WB EXIT RAMP COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 1 0)0 Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NW ❑ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FOR DAMAGEDAREA(S) FROPtf TOWED U1 O
0 6
( P
13-UNDER CARRIAGE 9 I I! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14--TOTAL(ALL) O DISTRACTED 0 ]$I U2 2 rr1
M 2 4 ❑Y ®SYSNEM❑UNK VEH. 0 AT CRASHD 0 99-UUTHER NKNOWN 9 76.70P 3 ,Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, i�a �i 4 COM VEH 0 j$J 1 0
ELGIN IL 60123 0 1 0 FIRST CONTACT 11 7_: __5 *Ilyes.SeeSidebar U1
ZDD73094 IL 2025 REAR
TELEPHONE
IL D 0 1J4RR5GT2BC71342 AMERICAN ALLIANCE ❑Y ®N U2 I''I
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same I LAA-0583418-08 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 c
m E{ DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL ❑EWES ❑iiuv 0 i v 0 Dv
yr �� 12 E FIRE ❑ ® U2 C o 13-UNDER CARRIAGE
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F 2 4 SYSTEM IN 0 ENGAGED 0 ®-OTHER 9,16•TOP()* X
❑Y ON DUNK VEH. AT CRASH 99-UNKNOWN O 0istracuon Value 9 0
POINT OF s it I• i 4 COM VEH D ® U1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR �J 5
FIRST CONTACT 2 7_ _, _5 •(ryes,See SidebarC
= HANOVER PARK IL 60133 0 1 SXW8470 TX 2025 REAR 0
IL D 0 3LNHL2GC9CR829963 Farmers Insurance ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 3LNHL2GC9CR829963 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER
u1 =
(UNIT) (SEAT) (DO81 (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
2 3 12 / M 2 3 0 1 0
m
/ / #OCCS >
71
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ®Y U2 Z
N 1 ® 11 1 61 /01 /025 07 56 ®AM in a Work Zone? 0 N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
O 2 ❑ 04 28 / / ❑PM ®Construction *
R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM ❑Maintenance U2
o ® 11 1 ARREST NAME Argumedo Garcia,Saul.O. 11-601-Ax 1564000006 / / El PM SLMT
o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' ❑Utility
0 AM
T 2 0 ARREST NAME 61 /01 /025 09 24 ®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? ❑V 45
1564-Rea, Desiree 701 71 , 51 /025 09 00 ❑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.
A CMV is defined asmotor vehicle used to transportand:
r ----,5-••--, ; any passengers or property
Z
1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
} }-- -i-- --; } } } ,- -, , ; ; , ; ( combination):or —I
INDICATE NORTH p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ' 1 , } (example:shuttle or charter bus):or
X
3. Is
L L.___A_._ 1 ____... . J transporting edmployeeslIn5 hecourseeo theire rsmployment example:employeener
} } }
transporter-usually a van type vehicle or passenger car):or 1:0
< <.__-a-_-_- , l' < <--_-a-___� . , , , 4. Is used ordesi nated to trans rt between 9 and 15 passengers,including C} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or 0
L L___-a____4 L L L ,.___-4_ ; l. i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). XI
CARRIER NAME Z
ADDRESS 0
T.
, n
, CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other 0
USDOT NO. ILCC NO. m
XI
Source of above z
). MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No 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
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
White Lavender
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 2 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE