HomeMy WebLinkAbout2025-00045714 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 011011000 000111 1111110011111111111111
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X463888551
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
El AMENDED
YR 2025I 2025-00045714 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
® ❑ RELATED ®Y 0 N 07 15 2025 IMAM ❑YES ®NO U1
BENT ST Elgin09:52
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FT!MI N E S W ST CHARLES ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 cn
❑ Kane HIT&RUN ❑V ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 —I
Igl AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 RIAU 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C)
0 3 !
yr
Martinez Nieves.Anthonynon Honda HR-V 2021 00-NONE ,, • 12 , DUE TOCRASH 0 13-UNDERCARRIAGE fal O 2 FIRE 0
0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 gi U2 m
M 2 SYTM IN ENGAGEDTHER
6 ❑Y ®SNEDUNK VEH. O AT CRASH O 99-U15-UNKNOWN 9 76-TOP® `Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR
POINT OF 6_iL 6 ii,; 4 COM VEH ❑ j$J 1 O
F. FIRST CONTACT 2 7_ —_;_-5 *lives.See Sidebar U1
Z Schaumburg IL 60194 B 1 0 EE47171 IL 2026 REAR
TELEPHONE
IL D 0 3CZRU6H5XMM750761 Kemper ®Y ❑N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Rodriguez Uruena. Luz.A. 12RA000081685 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 XI
x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0 NOV 0 Dv
!2 0 0 4 Scion TC 2009 00-NONE O-i Qi'-0 DUE TO CRASH gi ❑ 2 x
0 Yr 13-UNDER CARRIAGE 10( I 2 FIRE ID El U2 C
Ti
F 2 5 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y gi N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction value 9 0
6 i1 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF FIRST CONTACT 12 7�� B 1i COM VEH El ® U1 CO t.5 *If Yes.See Sidebar
n BARTLETT IL 60103 0 1 0 ED73433 IL 2026 I 0 C
IL D 0 JTKDE167990278656 State Farm ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Martinez 3419362-SFP-13 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 4 71 151 ,025 09 52 Ei 0 AM in a Work Zone? ®N DIRP co
1 t PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 7 n
T
0 2 ❑ 23 2 , ! ❑PM ❑Construction X
R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
-a, ARREST NAME Martinez Nieves.Anthony 11-1204-B 1540-267 / ! ❑PM SLMT
o u 1 ® 11 4 CITATIONS ISSUED 0 PENDING Utility
8lgiSECTION •CITATION NO. ROAD CLEARANCE TIME AM, ❑
t 2 El ARREST NAME Martinez Nieves.Anthony 3-707 1540-268 71151 ,025 10 40 [M PM El Unknown work zone type U1 30
2 2 3 0 OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME ®AM ❑Y 30
1540-Allahi. Muhammad 401 81 , 21 ,025 01 30 ❑PM Workers present? ®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
t.0 des? 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
` ` -' -' r INDICATE NORTH combination):or .Z�1
1 BY ARROW 2 Is used or designed to transport more than 15 C
g sp passengers including the driver �
} r r ,. (example:shuttle or charter bus):or 0
L
— 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
} } } transporting employees In the course of their employment(example:employee X
_ transporter-usually a van type vehicle or passenger car):or w
C
i. i..___a__...I _,aL-Unit 1— GUM 1 1. } } } •4. Is used or designated to transport between 9 and 15 passen including the driver,
® ® for direct compensation(example:large van used fors specific purose):or
Bent73t L ,. < < L 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
O
A '
s...-Ili m
pWcartling(example:placards will be displayed on the vehicle). �
D
FA
CARRIER NAME z
- ADDRESS 'n
I cITYlsraTF�zIP 0
w I MOTOR CARR.ID ❑ Interstate ❑ Intrastate
'�
I I I .� ❑ Not in Comm./Govt. Not in Comm./Other
;_...Y._._ USDOT NO. ILCC NO.
rTt
m
XI
Source of above z
. If Yes,Name on placard 0
4 digit UN NO. 1 digit Hazard class No. XI
XI
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z
own tank)? 0 Yes ❑ No 0 Unknown
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes ❑ No ❑ Unknown M
D
Did Carrier Safety Regulations(MCS)violation contribute to the crash?
El Yes Yes I 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 ❑Unknown Out of Service ❑Yes ❑No C
Z
Form Number 0
m
71
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
1-1
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Blue Blue
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: 3 TOWED BY/TO:
DUE TO ® Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE