HomeMy WebLinkAbout2025-00043054 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X 0367,99r
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S 0$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) El B Injury and/or Tow Due To Crash
0 AMENDED YR 2025I 2025-00043054 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 m® ❑ RELATED PRIVATE ❑Y ®N 07 04 2025 ❑AM YES ®NO U1 -<
CONGDON AVE Elgin mo /day/yr 04:55 ®PM FLOW CONDITION M
01 N /MI N E S O MOHAWK Dr COUNTY PROPERTY ❑Y M N DOORING ❑Y #OF MOTOR ❑SLOW 1 (n
Cook HIT&RUN ❑V ® N WITH VEHICLES INVLD ® STOPPED U2 —I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
tg:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 NW 0 Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FROM TOWED U1 Q
NAME(LAST,FIRST,M) mo
/1 9 6 2 Honda Ridgeline 2008 OD-NONE
13-UNDER CARRIAGE •„ 12!`_1 DUE TOCRASH El ENE
10 �. 2 FIRE 0 NI
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED THER ❑ 0 U2 2 rr1
M 2 SYTM 4 ❑Y ®$NE❑UNK VEH. O ATCRASHH 0D 99-U 15-UNKNOWN 9 16•TOP 3 ,Distraction Value 9 ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s it a 11. COM VEH ❑ Ea 1 C)
~ ELGIN I L 60120 0 1 0 FIRST CONTACT 6 O7 _: __5 *If Yes.See Sidebar U1 0
Z 1BETBN-B IL 2025 REAR
TELEPHONE
IL Other 0 2HJYK165X8H514768 COUNTRY FINANCIAL ❑Y ®N U2 1—
IL'13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same P12A8665850 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 ou
N DRIVER ❑ PARKED 0 DRIVERLESS 0 PEO 0 PEDAL 0 EWES 0 NAV 0 Ncv 0 Dv
/1 9 9 0 Toyota Corolla 2012 00-NONE 11 12 t2"-_, DUE TO CRASH ❑ 2 x
o 13-UNDER CARRIAGE 10 1 2 FIRE 0 ® U2 C
c
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN O *Distraction Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8_'�. 4 COM VEH 0 ® u1 CO
F,,, FIRST CONTACT 5 Y��_,'L(�5 •((Yes.See Sidebar C
ELGIN IL 60123 0 1 0 EV25824 IL 2025 I Si)0
IL Other 0 2T1BU4EE6CC908228 AMERICAN FREEDOM ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 LOPEZ MEDIA,WADY,A. 12-2479201-00 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
iUNIT) (SEAT( (D08) (SEX) {SAFT) (AIR) (INJI (EJCT( (EPTH) PASSENGERS&WITNESS ONLY (NAME(/(A.DDRESS)/(TELEPHONEI (EMS) (HOSPITAL)
2 4 04 /
2 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
u 1 El 11 1 07,04 /2025 04 55 ®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)
0
1
2 ❑ 30 99 , / 0 PM ❑Construction >E
R 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM ❑Maintenance U2
—a, U 1 ARREST NAME Newhouse. Benjamin. E. 11-1402-A 1551000136 / / ❑PM SLMT
o ER 1 CITATIONS ISSUED 0 PENDING Utility
o N SECTION •CITATION NO. ROAD CLEARANCE TIME AM• 0
T 2 El ARREST NAME Lopez Garay, Heydi,J. 6-101 1551000137 07/04 /2025 05 00 0 PM 0 Unknown work zone type U1 35
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 35
1551-Dede,Joseph 201 391-Jacobucci 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 truckrtrailer -<
` ` --I -' I. INDICATE NORTH combination):or .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- } (example:shuttle or charter bus):or
I
r 0
i ; ; 0Not To Scale f ` , 3. Is desgned to carry 15 or fewer passengers and operated by a contract carrier I O
1 - } } } transporting employees in the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or w
L L.___a__. 4. Is used ordesi natedtotrans transport passengers,including y} } } g po passen rs,includi the driver,
for direct compensation(example:large van used for specific purpose):or
l. a_ I - ? t i i i. _ 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
M
• placarding(example:placards will be displayed on the vehicle). m
_ 21
1 I I(I� D
- CARRIER NAME Z
ADDRESS O
w
C)
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
------------ - USDOT NO. ILCC NO. rn
XI
Source of above 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?
❑ Yes II No ElUnknown A
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. w
Green 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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE