HomeMy WebLinkAbout2025-00042841 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00387a045
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INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S 0$501-$1.500 ®ON SCENE 3
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 2O25I 2025-00042841 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED PRIVATE ❑Y ®N 07 03 2025 ❑AM ❑YES ®NO U1 -<
N STATE ST Elgin mo /day/yr 06:30 ®PM FLOW CONDITION Ill
�O C7/MI O E S W BIG TIMBER Rd COUNTY PROPERTY ElY M N DOORING ❑y #OF MOTOR 0 SLOW 15 cn
Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ® FREE FLOW # LNS 0
18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL ❑EWES ❑NW ❑!CV 0 DJ DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) 4 n
Y N
0 4 /
yr0Kia Motors Co tima 2015 00-NONE 11 DUE TOCRASH ® ❑
13-UNDER CARRIAGE 12! FIRE 0 NI
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED 0 0 U2 4 M
M 2 4 ❑Y ®SNEM❑LINK VEH. 0 AT CRASH IN ENGAGE0 99-UUNKNOWN 9 76•TOP 3 ,Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 iI 6 •
4 COM VEH 0 Ea 1 0
~ ELGIN N I L 60123 0 1 0 FIRST CONTACT 12 7_;1 __5 *Yves.See Sidebar U1
Z ET93451 IL 2026 REAP
TELEPHONE
IL D 0 SXXGM4A77FG413515 FIRST CHICAGO INSURANCE ❑Y ® —
N U2 1
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 99 9 Same I LS 959856-02 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 73
m g DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 iiuv 0 NCv 0 DV
'1 9 yf 1 General Motor rQ�a)p 2002 13-UNDE 'o,1 t2 (,-2 FIRE DUE OCRASH D ® U2 2
o 13-UNDER CARRIAGE
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 911,6•TOP 3 X
❑Y ®N DUNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF ®'i- 6 il;, 4 COM VEH D ® u1 CO
C
FIRST CONTACT 7 Q __,�_5 •)ryes.See Sidebar
ROCKFORD IL 61101 0 1 0 DQ17080 IL 2025 I 0 N
Z
IL D 0 1 G KDT13S422379740 KEMPER ❑y ®N RDEF73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
Elgin Fire 99 9 ALVARES MENDOZA.JOSE 12RA000035102 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME))(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
2 6 09 /
LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur IDY U2 Z
N 1 ® 11 1 07/03 /2025 06 30 ®AM in a Work Zone? ®N DIRP co
1 T PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
v 2 0 20 99 07,03 /2025 07 04 ®pM 0 Construction
R O ❑ xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
3 ❑AM 0 Maintenance U2
-a, ARREST NAME Wall, Kevin, R. 11-708 1551-000135 07/03/2025 07 05 Igi pM SLMT
CITATIONS ISSUED PENDING® 11 1 ❑ • Utility
o N I SECTION CITATION NO. ROAD CLEARANCE TIME El
T 2 El ARREST NAME 07/03 /2025 08 50 0 PM 0 Unknown work zone type U1 El AM 35
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 35
1551-Dede,Joseph 501 08 , 12/2025 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.
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 -<
i- }-- -'-- --' l I. INDICATE NORTH combination):or -I
0
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ } (example:shuttle or charter bus):or
Not To scale f 3. is designed tocarry 15 or fewer passengers and operated a contract carrier O
desg pa 9 pe by
I `
el II. } } transporting employees in the course of their employment(example:employee
(OW tlfinfei) transporter-usually a van type vehicle or passenger car):or w
L ' _ L 4. Is used or designated to transport between 9 and 15 passengers,including C
l } } } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or O
L L _
. I I � � t_ * - t i Iany
5. Is any vehicle used to transport hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). ;p
--'� CARRIER NAME Z
ADDRESS 0
�� I _ n
. . . . _
CITY/STATE/ZIP
I - i. i. MOTOR CARR.ID 0 Interstate El Intrastate
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
; _Y_ __; - USDOT NO. ILCC NO. m
XI
Source of above z
. 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
Maroon Silver
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: 3 TOWED BY1T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE