Loading...
HomeMy WebLinkAbout2025-00039702 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 011011000001 fl 00100 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003862015 u, 1 U2 1 1 1 U1 2 U2 1 U, 1 U2 U,99 U2 1 1 9 U123 U221 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El5501-51.500 ❑ON SCENE 7 VEHICLE/PROPERTY ®OVER$1,500 ®NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 2025512025-00039702 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n 729 JEFFERSON AVE Elgin03:15 ® ❑ RELATED ❑Y ®N 06 21 2025 ❑AM ❑YES IX]NO U1 —< _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR ❑SLOW 1 (n ❑ FT/MI NESW Cook HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I O AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0 Q83 DRIVER O PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 Nuv 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n FOR DAMAGEDAREA(S) FROPtf TOWED U1 Q Parra Rodriguez. Mayra. E. 0 4 / yr 13-UNDER CARRIAGE ©,I !�. 2 FIRE ❑ ® < STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ Ea U2 m F 2 4 Y SYSTEM IN ENGAGED 15-OTHER 9 16.70P 3 9 ALGN = ❑ ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF & it a �i COM VEH 0 Ea 1 m ~ ELGIN IL 60120 0 1 CS89864 IL FIRST CONTACT 11 7_; __5 *If Yes.SeeSideDar U1 0 REAR c Z E TELEPHONE IL D 4T1 KZ1AKXRU094457 State Farm ❑Y igi N U2 10 . m IS EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same 3581118 SFP 13 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER 73 D Refused ❑Y ❑ N 2 0 ❑ DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMv 0 NOV 0 DV CIRCLE NUMBER(S) U1 yr 0. 12 _ �1 o — 13-UNDER CARRIAGE 10'1 2 FIRE 0 ® U2 C c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR n SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP 3 9 0 a ❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN `Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 ) II'4 Ut to FIRST CONTACT 11 7 S ` .S •If ® C REAR 0 fn M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 JTDBCMFE7R3052361 Unique Insurance ❑Y ®N RDEF 7) EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 = 99 9 Londono Mustafa.Jose. D. ILP3437978 BAC $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (008) (SEX) {SAFT) (AIR) OM (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 18 5 06,21 l2025 04 25 ®AM in a Work Zone? ®N DIRP co 1 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) 2 ❑ 18 18 N 3 ❑ 0 CITATIONS ISSUED 0 PENDING + ! 0 PM• ❑Construction SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5 -a, ARREST NAME ! ! ❑PM ' o N ER11 5 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT 10 ARREST NAMEAM 7r 2 ❑ ❑❑PM ❑Unknown work zone type U1 , / n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ 547-Hometer.William 391-Jacobucci , , ❑❑pM 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. 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 truck trailer -< } i.-- -i-- --; } } } r -, , ; ; , ; ( INDICATE NORTH combination):or —I p1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } ' i I , } (example:shuttle or charter bus):or X 3. Is . L.-_------ 1 ..._- - J transporting edmployeeslIn5 hecourseeo theire rsmployment exam pal e:employeener 73} } } transporter-usually a van type vehicle or passenger car):or co < <.__-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---------_.: L L L ...._-..:__ ; t i i _ 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 0 Yes 0 No 0 Unknown Out of Service 0 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 Silver Gray 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: 2 TOWED BY/T6 DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE