HomeMy WebLinkAbout2025-00042358 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Df 2 Sheets 01111101111 011011000001110111I 0
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003878122
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INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
El AMENDED
YR 2025I 2025-00042358 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED ®Y ❑N 07 02 2025 ®AM ❑YES ®NO U1
DWIGHT ST Elgin06:14
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FT!MI N E S W ST CHARLES ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 2 fA
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD DO
U2 —I
Igl AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑Ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
Nieves.Anna. E. 0 7 /
yr 13-UNDER CARRIAGE 10.I !�. 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 2 m
F 2 4 El ® n 15-OTHER
SYSTEM❑UNK VEH. AT CRASH 99-UNKNOWN 9 16•TOP 3 `Distraction Value 9 ALGN 2
r B �i COM VEH 0 0 1 CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF & it 4
t° I Bloomingdale IL 60108 0 1 0 IL 2025 FIRST CONTACT 11 7_; __5 *If Yes.See Sidebar U1 O
REAR
c Z E
TELEPHONE
IL D 0 19FB2F95FE099047 ILLINOIS INSURANCE ❑Y ®N U2 m
IS EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 986074990 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y El 2 c
N DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES O New 0 Ncv ❑Dv CIRCLE NUMBER(S) U1
!1 9 y yf 6 Ford E450 Super Duty 1999 00-NONE 1t 12 0 DUE TO CRASH ❑ 2 x
o - 13-UNDER CARRIAGE 10 2 FIRE ❑ ® U2 C
c
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 t6-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistrac on Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S 1 B i',.4 COM VEH ❑ ® Ut CO
FIRST CONTACT 1 Y��_, _5 •IfYes.See Sidebar C
H ELGIN Z IL 60120 0 1 0 584AC622 IL 2025 I Si)0
M
IL D 0 1 FDAF56F8XED43191 PEKIN INSURANCE ❑Y ®N RDEF M
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 006441410 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER 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 0 Y U2 Z
N 1 El 11 2 07,02 l2025 06 14 ®❑AM in a Work Zone? NJ 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 n
0 T
2 ❑ 2 99 / / 0 PM- ❑Construction *
Z 3 0 1!>I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
o1 ® 11 1 ARREST NAME Nieves,Anna, E. 11-901-A 1544000166 / ! El PM SLMT
o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
r 2 ❑ ARREST NAMEAM
x- T 1 / ❑❑PM 0 Unknown work zone type U1
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1544-Solis,Yulissa 401 331-Ziegler 08 ,28,2025 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-_--; } combination):or —I
ereaw«s INDICATE NORTH P1
N BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
I _ (example:shuttle or charter bus):or
r
3. Is designed to carry15 or fewer passengers and operated a contract carrier 0
I- <_---A-----I I ` }} } transporting employee In the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or CO
owgrRrw
L 4. Is used or designated to transport between 9 and 15 passengers,including C}--- ----; �� - } } } g po passen rs,includi the driver,
, for direct compensation(example:large van used for specific purpose):or
L L____a____. 1111:1,) t 5 Isanyvehcleusedtotransportan hazardous material(HAZMAT)thatrequires m
placarding(example:placards will be displayed on the vehicle). ;p
11111.1
-1
CARRIER NAME Z
ADDRESS 0
D
Not TO Scale r CITY/STATE/ZIP �
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 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
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
Gray Red
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Adieu/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE