HomeMy WebLinkAbout2025-00043627 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
I011011000 00110 1111100
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00388:279
u, 1 U21 2 4 1 U1 2 U2 1 U, 1 1_12 1 U, 1 U2 1 1 15 U1 1 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 El$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER 91,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 202512025-00043627 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
WALNUT AVE Elgin® ❑ RELATED ®Y 0 N 07 06 2025 ®AM YES ®NO U1 -<
10:48
_ _ PRIVATE mo /day/yr ❑PM FLOW CONDITION Ill
FT!MI N E S W J EWETT ST COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR El SLOW 1 (n
❑ Kane HIT ❑Y ® N WITH VEHICLES INVLD El STOPPED U2 —I
El AT RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!Cy 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
FOR DAMAGEDAREA(S) FRONT TOWED U1 O
Carcamo. Marcio. L. 0 2 /
yr 13-UNDER CARRIAGE EN
10.I !�. 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
M 2 4 SYTM❑Y ®SNE DUNK VEH. O AT CRASH 0 99-UNK 15- NOWN THER9 16•TOP 3 `Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s it ii,4 COM VEH 0 j$J 1 0
ELGIN N I L 60123 0 1 0 FIRST CONTACT 11 7_;1 __5 *IIYes.See Sidebar U1
Z ES65256 IL 2025 REAR
TELEPHONE
IL D 0 1 G 1 ZC5EB8AF138530 State Farm ❑Y ®N U2 M
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
to
Elgin Fire 99 9 Same 0222561-SFP-13 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 2 ou
g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 New
/1 9 9 8 Ford Focus 2012 00-NONE 11_"1 Q1:O DUE TO CRASH rg ❑ 2 x
o Yr 13-UNDER CARRIAGE 10) I 2 FIRE 0 ® U2 C
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istrac on Value 9 g
POINT OF s i 4 COM VEH ❑ ® U1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR e �S:_ C
FIRST CONTACT 1 7 _,-_5 C.
If Yes.See Sidebar
Z Aurora IL 60505 B 1 0 EV25820 IL 2025 I 9
Z
IL D 0 1 FAHP3H24CL163149 American Alliance ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire 99 9 Same I LAA-1062186-00 BAC
E
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)
D
/ / 4 0
U EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur 0 Y U2 Z
N 1 ® 11 4 71 /12 /25 10 49 ❑PM in a Work Zone? ®N DIRP D
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 C)
T
0 2 ❑ 2 23 / / ❑PM ❑Construction
Z 3 0 Igi CITATIONS ISSUED El PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM ❑Maintenance U2
o1 ® 11 4 ARREST NAME Carcamo. Marcio. L. 11-901-A 499000832 / / ❑PM SLMT
o Nu ElCITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
t 2 ❑ ARREST NAME AM
T ( / pM El Unknown work zone type 35
U1
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 35
499-Dirck.Cameron 701 81 / 61 /025 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 A
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
i- `-- --I-- --' N - I. INDICATE NORTH combination):or -I
Not To Scale I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- } (example:shuttle or charter bus):or
X
L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
} I• } transporting employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
C
L L.---a. ...l 4. Is used or designated to transport between 9 and 15 passengers,including the driver,
I I } } } for direct compensation(example:large van used for specific purpose):or 0
L L____a..... 1.] [if t l. l 1 t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
vwMMnxw,M
placarding(example:placards will be displayed on the vehicle). XI
i -
CARRIER NAME Z
Z
- Lowry ADDRESS O
, O
CITY/STATE/ZIP C)
" " 1 II r
_ MOTOR CARR.ID 0 Interstate 0 Intrastate 5' ❑ Not in Comm./Govt. ❑ Not in Comm./Other 00
I. --- "1 USDOT NO. ILCC NO. C
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 ❑ 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
to
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
Beige Red
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Other/Unknown . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE