HomeMy WebLinkAbout2025-00045478 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X463888606
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑5501-51.500 ®ON SCENE 3
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 2025I 2025-00045478 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r7
® ❑ RELATED PRIVATE ❑Y ®N 07 14 2025 ®AM ❑YES ®NO U1 -<
EASTBOUND RT.20 Elgin mo /day/yr 10:47 ❑PM FLOW CONDITION M
•
010�/MI NOS w RANDALL Rd COUNTY PROPERTY ❑Y ® N DOORING ❑v #OF MOTOR 0 SLOW 1 (n
Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
183 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑NIAV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 6 n
0 8 /
yr 13-UNDER CARRIAGE / ! FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O 2 DISTRACTED ® 0 U2 6 I'T7
F 2 4 SYTM❑Y ®SNE DUNK VEH. O AT CRASH 0 99-U 15-UNKNOWN THER9 76•TOP 3 `Distraction Value 5 ALGN •
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s.;il_6 1,.4 COM VEH 0 El 1 0
~ ELGIN N I L 60120 0 1 0 FIRST CONTACT 1 O 7 ; _5 *II Yes.See Sidebar U1
Z DJ78097 IL 2025 REAR
TELEPHONE
IL D 1G1BE5SM2K7125673 GEICO ❑Y ®N U2 1--
5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
ARIZMENDI RODRIGUEZ.ANA. D. 6215433381 1 r
5HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2
N DRIVER 0 PARKED ❑DRIVERLESS ❑ FED ❑PEDAL 0 EWES ❑NIAV 0 NCv ❑DV
/1 9 8 7 Toyota Corolla 2022 00-NONE ,�"j t2 -_, DUE TO CRASH p (� 2
0 13-UNDER CARRIAGE 10 1 2 FIRE ❑ ® U2 C
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F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOPO3
❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN O Oistraellon Value U1 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s II 4 CO 16 [,k._ COM VEH ❑ ®
FIRST CONTACT 3 7-_,__5 •If Yes,See Sidebar C
Dekalb IL 60115 0 1 0 FC98265 IL 206 I 0 Si)
IL D SYFEPMAE1 NP382295 AMERICAN ALLICANCE ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same I LAA104206300 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
RESPOND❑Y0N u1 =
Y
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME(1(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
1 6 09 / F 13 4 0 1 0
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/ / #OCCS D
71
/ / UI 2 D
/ / 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 El 11 1 71 ,4/ /025 10 47 ®❑PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
o"
2 0 20 99 / / ❑PM ❑Construction >F
Z 3 0 lyg CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM 0 Maintenance U2
a ENRIQUEZ.VIVIANA 11-709-A 244-1819 / / PM
-, ARREST NAME El
o N 1 ® 11 1 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT
55
r 2 ❑ ARREST NAME AM
7 / / pM 0 Unknown work zone type U1
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 55
244-Blomberg. Michael 702 81 / 61 /025 01 30 0 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 -<
c ` -' -' r 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
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- ------;----. - transportingd mploned to aeeslin the course of 5 or fewer he r emplrs oyment(example:employee a contract ner X
_Not lb eoaN } r } transporter-usually a van type vehicle or passenger car): r CO
L L.___a__ 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or 0
L--__a-___; '. i i t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
ROUTE?207EASTBOUND XI
placarding(example:placards will be isplayed on the vehicle). �
ROUTE?201EASTBOUND _ --IICARRIER NAME
Z
ADDRESS
n
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other
-----------1 - USDOT NO. ILCC NO. rn
XI
Source of above z
. Was a driver/vehicle Examination Report Form completed? r
HAZMAT ❑Yes 0 No ❑Unknown Out of Service ❑Yes ❑No :
MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No C
Z
Form Number 0
m
Xt
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' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
White Blue
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 DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE