HomeMy WebLinkAbout2025-00044455 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111 I011011000 00
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003 .86212
u, 1 U21 2 4 1 UI 3 U2 1 U, 1 1_12 1 U, 1 U2 1 5 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 ❑5501-51.500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 2O25I 2025-00044455 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 "I
® ❑ RELATED ®Y ❑N 07 10 2025 ®AM ❑YES ®NO U1 -<
WALNUT AVE Elgin00:04
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FT!MI N E S W ELM ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑Nuv ❑ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
FOR DAMAGEDAREA(S) FRONT TOWED U1 0
Garcia Esteban.Ana.G. 08 /
yr 13-UNDER CARRIAGE 10, •12! 2 FIRE 0
IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 0 m
F 2 SYTM IN ENGAGEis-OTHER
4 ❑Y ®SNE❑UNK VEH. 0 ATCRASHD 0 99-UNKNOWN 9 76•TOP 3 `Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 2 1l all,' 4 COM VEH 0 �! 1 n
~ ELGIN I L 60123 0 1 0 FIRST CONTACT 7 O7 :;,-:-_5 *II Yes.See Sidebar U1 0
Z EA15910 IL 2026 REAR
TELEPHONE
OTH Other 9 1J4NT2GB7AD531622 Unique Insurance ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Estaban Yaneth.Garcia ILP3348428 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y 0 N 2 XI
g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑!My 0 NOV ❑DV
a3y !1 9 8 6 Tesla Model 3 2018 00-NONE O1 12.._1 DUE TO CRASH rg ❑ 2 x
0 13-UNDER CARRIAGE o I 2 FIRE ❑ ® U2 C
Ti
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistrac) n Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 .i.�.._ 4 COM VEH ❑ ® U1 W
FIRST CONTACT 11 7 , _5 •if Yes.See Sidebar C
ELGIN IL 60123 0 1 0 EK71838 IL 2026 I 0 Si)
Z
IL D 7 5YJ3E1 EA8JF048919 Tesla Insurance Co. ❑Y J N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same TLA-IL-A-99933DPT BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused 0 Y°ND
0 N U1 =
KNIT) (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 ❑Y U2 Z
N 1 ® 11 4 07,10 /2025 00 05 ®❑AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 4
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1 C)
v 2 2 99 07,10 ,2025 00 05 ❑PM ❑Construction *
1
R 3 ❑ ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVE° TIME 7
z J ®AM ❑Maintenance U2
o1 ® 11 4 ARREST NAME Garcia Esteban.Ana.G. 11-1204-B 467-471 07/10/2025 00 10 ❑PM SLMT
o N 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME- • 0 Utility
AM U1 30
r 2 ❑ ARREST NAME 07/10 /2025 00 51 [�PM ❑Unknown work zone type
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 30
467-Banks. Hannah 701 331-Ziegler 08 , 12,2025 01 20 ®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
r combing r gmore than pound { a p .truck or truck/trailer 1. Has a weight ratio 10 000 s exam le' i -<
r INDICATE NORTH tan)o p0
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
NotI [.. To Scale } (example:shuttle or charter bus):or
i 3. Is d fined t carry 5 fewer passengers and operated a contract carrier O` 1J I es o , or
- } } } transporting employees In the course of their employment� (example:employee � �
y a van type
L L.___a____� transporter sed or designated to transehrt betweeicle or n9andr 15r) ssen rs,including the driver. C
C / r } for direct compenation(example:large van used for specific purpose):or N
` h---_a----i WaI nut?Ave. - _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
•u
placarding(example:placards will be displayed on the vehicle). XI
IT - . . CARRIER NAME Z
I ADDRESS 0V)
ITT-
t O
CITY/STATE/ZIP C)
_ MOTOR CARR.ID 0 Interstate El Intrastate
❑ Not in Comm./Gout. ❑ Not in Comm./Other 00
r r - - -- USDOT NO. ILCC NO. m
m
XI
Source of above z
. • m
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 iO No 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
Xi
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 0 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Silver Silver
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 1 TOWED BY/TO.
SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE