HomeMy WebLinkAbout2025-00040813 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 011011000 01101 fll 00 0
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
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 2025-00040813 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED ®Y 0 N 06 26 2025 ®AM ❑YES ®NO U1 -<
N EDISON AVE Elgin08:31
g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FT!MI N E S W W CH ICAGO ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 3 Cl)
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EOUES 0 NOV 0 ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
FOR DAMAGEDAREA(S) FRONT TOWED U1 Q
Garcia-Es inoza. Kervin.C. 0 1 /
yr 13-UNDER CARRIAGE �a:) 2 , 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 O m
M 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 _
ID N DUNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S,_iL S 4 COM VEH 0 Ea 1 0
~ ELGIN N I L 60123 0 1 0 FIRST CONTACT 12 7 ; _5 *Irves.See Sidebar U1
Z FA48244 IL 2025 REAR
TELEPHONE
IL D JTDKN3DU4B1381857 Direct Auto ❑Y ®N U2 13 , m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Rogriguez-Flores.Amanda, L. PAI L001241725 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 XI
�{ DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑ uv 0 Ncv ❑Dv
!1 9 yf 4 Honda Odyssey 2012 00-NONE ,0'1 12 (,-2 DUE FIREO CRASH rg ® U2 2 C
o 13-UNDER CARRIAGE III
c
M 2 8 SYSTEM IN ENGAGED 15-OTHER 9.1,6•TtOP 3 0 X
❑Y ❑N DUNK VEH. AT CRASH 99-UNKNOWN 1 O *Distraction Value
POINT OF S l' j1 4 COM VEH D ® U1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR �J 5
FIRST CONTACT 4 7_ _,�_5 •(ryes,See Sidebar
H Hampshire IL 60140 A 1 0 300150 IL 2025 I 0
IL D 5FNRL5H92CB078400 State Farm ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire Same 1370050SFP13 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Provena St.Joseph RESPONDER® 3 u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (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 ® 11 4 06,26 l2025 08 31 ®❑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)
v 2 ❑ 2 23 06,26 ,2025 08 32 ❑PM ❑Construction >E
r' 3 ❑ ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
z J ❑AM ❑Maintenance U2
ou ® 11 4 ARREST NAME Garcia-Espinoza. Kervin.C. 11-901-A 298001256 06/26/2025 ❑PM SLMT
o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
AM 30
r 2 El ARREST NAME 06/26 /2025 09 31 MPM ElUnknown work zone type U,
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 30
298-Lopez, Mirko 601 07 , 14,2025 01 30 0 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 truck trailer -<
` ` -' -' r INDICATE NORTH combination):or —I
' . 0. BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
$ N, _ - } (example:shuttle or charter bus):or
3. Is designed tocarry 15 or fewer passengers and operated a contract carrier I O
I y I. } } transportinggemployees in the course of their employment
typepassen car):(orxample:employee w
transporter-usuallya van vehicle or
L L.___a.._..i - 4. Is used ordesi natedtotrans rtbetween9and15passengers,includingthedriver. C
�t���d EdIson?Ave } } } •
for direct compensation(example:large van used for speific purose):or N
L L____a...J ow. - L L L t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
- _anal
i placarding(example:placards will be displayed on the vehicle). XI
I1 CARRIER NAME Z
I _ ADDRESS 0
D
Not To scale j ,
CITY/STATE/ZIP 0
MOTOR CARR.ID 0 Interstate El Intrastate
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
--- --1 USDOT NO. ILCC NO. m
XI
Source of above z
. Form Number
m
Xl
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 0 0 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Silver Beige
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Other/Owners Residence . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE