HomeMy WebLinkAbout2025-00040403 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
011011000 01101 0100
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003665905
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 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 14
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 2025I 2025-00040403 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
ROYAL BLVD Elgin 01:25
® ❑ RELATED ®Y 0 N 06 24 2025 ❑AM ❑YES ®No u1
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W SCOTT DR COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR El SLOW 1 cn
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ® FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEOAL 0 EOUES 0 uuv 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C)
0 3 /
yr 12 _
13-UNDER CARRIAGE 10 i 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O THERDISTRACTED ❑ gi U2 0 m
F 2 SYTM 4 ❑Y ®$NE❑UNK VEH. 0 ATCRASHD 0 15-99-UUNKNOWN 9 16•TOP 3 `Distraction Value 9 ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 7 it S �i 4 COM VEH 0 j$J 1 0
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ELGIN N I L 60123 0 1 0 FIRST CONTACT 2 7_;- -_5 *IrYes.See Sidebar U1
Z EV21043 IL 2025
TELEPHONE
IL D 0 JTEDS43A282047646 Unique ❑Y ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
99 9 Buitrago.Wilmar.A. I LP3405982 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 ou
p;rg- DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uv 0 KCV 0 Dv
1 9 5 8 Jeep(after 19681�rokee 2011 00-NONE i1_"j Qr,-_, DUE TO CRASH gi ❑ 2 x
.. y yr 13-UNDER CARRIAGE 10( I. 2 FIRE ❑ ® U2 C
M 2 8 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑YNi N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistractlon value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-iI�1:,-4 COM VEH ❑ ® U1 CO
FIRST CONTACT 12 7 .5 •If Yes.See Sidebar
Z South Elgin IL 60177 B 1 0 H FK890 IL 2025 I 9 n
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IL Other 0 1J4RR4GG2BC570195 Encova ISI Y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 5001345221 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ®Y U2 Z
N 1 El 11 4 61 /41 /025 01 25 ®AM in a Work Zone? ❑N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
2 ❑ 2 99 61 (41 /025 O1 50 ®PM ®Construction
R 3 ❑ gi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ELMS ARRIVED TIME 7
z J ❑AM ❑Maintenance U2
-a, ARREST NAME Velazquez Orjuela. Laura.S. 11-901-A 1530000403 61 /41 /025 01 53 Igi pM SLMT
o U 1 ® 11 4 El CITATIONS ISSUED 0 PENDING -
o N SECTION CITATION NO. ROAD CLEARANCE TIME AM• 0 Utility
t 2 El ARREST NAME Quirk. Michael.A. 3-707 1530000404 61 /41 /025 02 05 ®PM ❑Unknown work zone type U1 15
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME CO
®AM Workers present? ❑Y 15
1530-Soto.Oscar 502 81 / 12 /25 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.
r ----r••--, , N . A CMV is defined as any motor vehicle used to transport passengers or property and: Z
1 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
` ` --I- -' r INDICATE NORTH combination):or —I
Not To Scale 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 0
L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I
} } } transporting employees in the course of their employment(example:employee 73
L i.-----}----; Royal?BlvdI - } } } } C
transporter. sed or des gnated to transport between 9 and 15 passengers,including the driver,
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for direct compensation(example:large van used fors specific purose):or 0
_7 I ;- LUnit i. < i. L 5. Is anyvehicle used to transport anyhazardous material(HAZMAT)that requires m
1 --
l■ ,___) placarding(example:placards will be displayed on the vehicle). D
P.O.,. _I
unit 1 CARRIER NAME Z
ADDRESS 0
T
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CITY/STATE/ZIP .>
MOTOR CARR.ID ❑ Interstate ❑ Intrastate
I I T I ❑ Not in Comm.lGaA. Not in Comm./Other0
Scott?Dr USDOT NO. ILCC NO. m
XI
Source of above z
'
. 0 Yes 0 No ❑ Unknown A
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
Silver Red
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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE