HomeMy WebLinkAbout2025-00038975 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0036.63460*
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500
El NOT ON SCENE(DESK REPORT)
0 AMENDED ElB Injury and/or Tow Due To Crash YR 202512025-00038975 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
951 ELIZABETH ST El In11:22
® ❑ RELATED ❑Y ®N 06 18 2025 12'''' ❑YES ®NO U1 -<
g PRIVATE mo /day/yr ®PM FLOW CONDITION ITl
_
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 rA
❑ FT/MI NESW 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 O PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0 Icy CI Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
Mao TOWED U1 Q
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NAME(LAST,FIRST,M) mo
Willis.Jaelon. D. Kia Motors Cof�adenza 2015 00-NONE „ O , OUETOCRASH ❑
yr 13-UNDER CARRIAGE ) FIRE ❑ IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 1U O DISTRACTED 0 0 U2 2 m
M 2 4 ❑Y OSYNM®UNK VEH. 9 AT CRASHH D 9 99-UNKNOWN 9 76•TOP�3 *Distraction Value 5 ALGN
-
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i� S �I COM VEH 0 1� 2 O
~ Roselle IL 60172 0 1 0 FIRST CONTACT 12 7_; _5 *IIYes.SeeSidebar U1
Z BM4696 IL 2025 REAR
TELEPHONE
IL D KNALN4D78F5182584 State Farm ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
Willis. Rhonda 3529555-SFP-13 2 m
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 X
❑ DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0!My 0 NOV 0 Dv
yr Toyota Corolla 2024 00-NONE ,�_ t2"-_, DUE TO CRASH ❑ ® 1
o 13-UNDER CARRIAGE o I 2 FIRE 0 ® U2 C
Ti SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED
a SYSTEM IN 9 ENGAGED 9 15-OTHER 016•TOP 3 0 ® SPDR 0
❑Y ❑N ®UNK VEH. AT CRASH 99-UNKNOWN *Oistrac on Value 9 U1 0 -
POINT OF s ) -4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR _ l!._ C.OM VEH ❑ ® CO
F,,, FIRST CONTACT 9 7 _, _5 •If Yes.See Sidebar
ER87691 IL 2025 I 0 Si)M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
5YFB4MDE2RP159003 American Freedom ❑Y J N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
Tinajero. Elizabeth 12-2436855-01 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
iUNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(A.DDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
1 4 02 / F 2 4 0 1 0
m
/ / #OCCS D
71
/ / UI 2 m
/ / 0 O
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 18 1 06,18 /2025 11 22 ®AM in a Work Zone? ®N DIRP co
I t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
o"
2 0 28 20 / / ❑PM 0 Construction *
Z3 0 Igi CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2
o 1 ® 11 1 ARREST NAME Willis.Jaelon. D. 6-101* W1534000269 / / El PM SLMT
igi CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility
o N 0 AM 30
t 2 0 ARREST NAME Willis.Jaelon. D. 11-601-Ax 1534000267 , / pM 0 Unknown work zone type U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 30
1534-Santiago.Jorge 401 331-Ziegler 07 , 15/2025 01 30 ®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 truckrtrailer -<
` ` -' -' 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
r r r X
3. Is desgned to car 15 or fewer ssen ers and o rated a contract carrier O
- } } . transporting employees In the courses of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
L L____a____� 4. Is used ordesi natedtotrans rtbetween9and15passengers,includingthedriver. C
VMt�
I r � • } } for direct compensation(example:large van used for speific purose):or 0
-i unrtr,am i ny.n Er*k — — — - i. . i. �_ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
unnri*al Inv.,y , ( I t placarding(example:placards will be displayed on the vehicle). XIeipimAve
r
ar CARRIER NAME Z ADDRESS O
T.
CITY/STATE/ZIP 00
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
--- --1 - USDOT NO. ILCC NO. m
XI
Source of above z
. If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. Xl
Xl
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 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
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 Gray
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: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE