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HomeMy WebLinkAbout2025-00041059 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I01101100000 HIE 11111111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY *X003670170* u, 1 U21 1 1 1 U1 2 U2 1 U, 1 1_12 1 U, 1 U2 1 1 10 u1 3 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW ' Elgin Police Department ONE PERSON'S 1215501-51.500 ®ON SCENE 1 VEHICLE/PROPERTY ❑OVER 51,500 ❑NOT ON SCENE(DESK REPORT) El AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00041059 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn ® ❑ RELATED ' ' 0 N 06 27 2025 ®AM El YES ®NO U1 -< N STATE ST Elgin10:56 _ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m FT!MI N E S W SGH I LLER ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 -I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0 Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n FOR DAMAGEDAREA(S) •FROf tf�TOWED VI U1 0Moreno. Luisa 0 2 / yr 13-UNDER CARRIAGE I FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED ❑ 0 U2 4 <<Tl F 2 SYTM IN ENGAGE4 ❑Y ®SNE El UNK VEH. 0 AT CRASHD 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, it a �i COM VEH ❑ j$J 1 0 ~ ELGIN IL 60123 0 1 0 FIRST CONTACT 1 7 ;1 __5 *IIYes.SeeSidebar U1 Z FC71256 IL 2026 E 7 TELEPHONE IL D 1 HGCM66524A054151 First Chicago Insurance ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Tapia Ayala. Delia I LS1165853-00 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 c m x DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED 0 PEDAL 0 EWES 0 NMV 0 KCv 0 Dv 9 9 1 Toyota Corolla 2011 00-NONE al 2 i'-_, DUE TO CRASH ❑ 21 2 x o 13-UNDER CARRIAGE U I ©Ic, 2 FIRE ❑ ® U2 C F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16•TOP 3 X ❑Y Ni N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 0 POINT OF 8 i1�. 4 COM VEH D ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR a FIRST CONTACT 11 7 _5 •If Yes.See Sidebar Z Schaumburg IL 60193 0 1 FL60897 IL I C 0 cn D NM D 2T1 BU4EE7BC654155 Allstate ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X Barth. Robert 802946386 BAC $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (DOB) (SEX) {SART) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) U2 996 r m ##occs > / ,, U1 1 Ill 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 11 4 06,27 ,2025 10 56 ®❑pM in a Work Zone? ®N DIRP co 1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY •CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 3 C1 T 0 2 ❑ 2 06 1 , 0 PM ❑Construction * R 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 o ® 11 4 ARREST NAME Moreno. Luisa 11-902 1547000100 / ! El PM SLMT o Nu ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility 35 t 2 ARREST NAME AM T 1 1 ❑❑PM 0 Unknown work zone type U1 El 2 2 3 0 OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 35 1547-Steele.Justin 501 08 ,05,2025 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.-- -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 1 , } (example:shuttle or charter bus):or X 3. Is . L.___A_. . ..._- - . transporting edmployeeslIn5 hecourseeo theire rsmployment example:employeener } } } transporter-usually a van type vehicle or passenger car):or co < <.__-a-_-_, , l• < <--_-a-___� , , , , 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or 0 L L___-a____.: 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 --I CARRIER NAME Z ADDRESS 0 T. CITY/STATE/ZIP MOTOR CARR.ID 0 Interstate ❑ Intrastate 0 ❑ Not in Comm./Govt. ❑ Not in Comm./Other O USDOT NO. ILCC NO. m XI Source of above z . If Yes,Name on placard 0 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 v TRAILER WIDTH(S) 0-96" 97-102" >102' m TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Silver Silver 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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE