HomeMy WebLinkAbout2025-00042584 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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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 15
VEHICLE/PROPERTY ®OVER$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 2025I 2025-00042584 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 71
CLARK ST Elgin10:00
® ❑ RELATED ' V 0 N 07 02 2025 ❑AM ❑YES ®NO U1 -<
_ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION m
FT!MI N E S W BUCKEYE ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR IR SLOW 15 u)
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!Cy 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 1 C)
0 6 /
EN
yr 13-UNDERCARRIAGE 10l �. 2 FIRE 0IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14--U
TOTAL(ALL) DISTRACTED 0 0 U2 1 r<11
F 2 THER
4 ❑Y ®SYSNEM IN n ENGAGED n❑UNK VEH. 0 AT CRASH 0 99-UNKNOWN Ole-TOP 3 ,Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 9 it �i 4 COM VEH 0 j$J 1 n
~ ELGIN I N I L 60123 0 1 0 FIRST CONTACT 4 O7 _: R--5 *If Yes.See Sidebar U1 0
Z BA61125 IL 2025
TELEPHONE
IL D 0 5FNRL38479B002981 GEICO El ® 4 U2 1-
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 TORRES VASQUEZ. REYNA.A. 6155292276 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER
2 As
p; DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMV 0 NCv 0 DV
yr
+2 0 0 4 Toyota RAV4 2018 oo-NONE ,� j Qj-O DUE TO CRASH p 2
13-UNDER CARRIAGE I FIRE ID El U2
c
F 2 4 SYSTEM IN 0 ENGAGED 0 ®-OTHER 9 16-TOP 3 9 0 X
❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-iI 6 ii, COM VEH 0 ® U1 CO
FIRST CONTACT 1 Y _, _5 •(ryes,See Sidebar
= ELGINREAR C
D IL 60123 0 1 0 EN91140 IL 2025
IL D 0 2T3RFREV9JW707836 Geico ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 61274716479 BAG E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
KNIT) (SEAT) (0081 (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
E/ MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 4 07,02 l2025 10 00 ®AM 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 5 n
T
0
2 ❑ 2 28 1 / 0 PM- ❑Construction *
Z3 0 lyg CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2
a ® 11 4 ARREST NAME Reyes. Iris. I. 11-601 1564000017 / ! El PM SLMT
o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' El Utility
0 AM
t 2 ElARREST NAME 07 r 02 12025 11 00 ®PM ElUnknown work zone type U1 25
2 2 3 ❑ OFFICER ID SIGNATURE BEAT I DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 25
1564-Rea. Desiree 501 08 , 19,2025 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 as for vehicle used to transportand:
r ----,5-••--, ; any motor passengers or property
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1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
- 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
} ' , } (example:shuttle or charter bus):or
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3. Is L L.-_-A.-- 1 i. <--_- -___� J transporting employened to es Inhecourse 5 or fewer o their eers mplod yment example:employeener X
} } }
transporter-usually a van type vehicle or passenger car):or CO
F F----------I , F I' I- <--_-a-___� 1 , , , 4. Is used ordesi natedtotrans rt between 9 and 15 passengers,including C} for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or 0
L L---------_.: L L L ...._-.�____� l. 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
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CARRIER NAME Z
i.
ADDRESS 0
, n
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other 0
-Y- --, , I- ; ; ; I.
USDOT NO. ILCC NO. m
XI
Source of above z
. MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No 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
Blue Black
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: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE