HomeMy WebLinkAbout2025-00045543 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
011011000 l I
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003689505
u, 1 U29 2 4 1 U, 2 U2 U, 1 U299 U, 1 u2 99 1 2 U1 1 U2 1 *P 0119*
INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑$501-51.500 ®ON SCENE 14
VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash yR 202512025-00045543 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
® ° RELATED PRIVATE ❑Y ®N 07 14 2025 ❑AM ❑YES ®NO U1 -<
DWIGHT ST Elgin mo /day/yr 03:40 ®PM FLOW CONDITION m
^20 ® ® COUNTY PROPERTY 0 Y ® N DOORING ❑y #OF MOTOR ❑SLOW 99 Cl)
12Sr !MI N E SSt.Charles St WITH VEHICLESOT,
INVLD ❑ STOPPED U2 —I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑Y ® N PEDALCYCLIST®N ® FREE FLOW # LNS 0
Ig:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FOR DAMAGEDAREA(S) FROr tf TOWED U1 Q
Torres. Ke ondra. M. 0 1 /
yr
13-UNDERCARRIAGE EN
fal O 2 FIRE 0NI
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 m
F 2 SY4 ❑Y ®SNEM❑UNK VEH. 0 AT CRASH 0 IN ENGAGEDis-OTHER
99-UNKNOWN 9 76•TOP 3 *Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S_iL a ii,4 COM VEH 0 j$J 1 0
~ ELGIN IL 60123 0 1 0 FIRST CONTACT 2 7_; __5 *IIYes.SeeSidebar U1
Z EY14939 IL 2025 REAR
TELEPHONE
IL D 0 1 G 1 ZD5ST9J F246889 None ❑Y ❑N U2 I—
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Macon. Diante None 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 ou
❑ DRIVER ❑ PARKED 0 DRIVERLESS 0 PED '}�. PEDAL 0 EWES 0
yr 10 j t2 (, 2 FIRE ❑ ® U2 C
o 13-UNDER CARRIAGE
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED ®-OTHER 9:1,5•TOP 3 0 ® SPDR n
5 9 ❑Y 0 N ❑UNK VEH. AT CRASH 99-UNKNOWN •Oistractlon Value U1 0 -
POINT OF s- i _4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 99 7 =)=.=5 C•IO f VEH
Sidebar° ® C
0 9 1.0
REAR t,
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
NIA ❑y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
1 48 2 Same NIA BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
RESPONDER❑ U1 =
Y
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(A.DDRESS)1(TELEPHONE) (EMS) (HOSPITAL)
996 r
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 13 1 07,14 ,2025 03 49 ®pm in a Work Zone? ®N DIRP co
1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 7 C)
T
0
2 0 2 99 , , ❑PM• ❑Construction
Z , 3 0 Igi CITATIONS ISSUED El PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 5
a ® 13 5 ARREST NAME Torres. Keyondra. M. 11-901-A 1512560 , ! El PM SLMT
j$[CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM• El utility
r 2 0 ARREST NAME Torres. Keyondra. M. 3-707 1512561 07 r 14 ,2025 03 50 0 PM 0 Unknown work zone type U1 30cf
n T OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME y
2 2 3 0 1512-Juarez-Huichapan.Juan 400 269-Mendiola 08 ,05,2025 01 30 0 PM Am 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
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
`----'-----; 0
- ) INDICATE
ARROW NORTH
combination):or C
BY2 Is used or designed to transport more than 15 passengers including the driver n
y r r (example:shuttle or charter bus):or 0
I r g Not To Scale I 3. Is designed to carry15 or fewer g g passengers and operated by a contract carrier I 0
-- al - . - . transporting employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
_ 4. Is used or designated to transport between 9 and 15 passengers,including (I)
} } } for direct compensation(example:large van used for speific purpoe):or
the driver,
O
L i.____a____j =>'I _ t i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
— — — Lk*r - - - placarding(example:placards will be displayed on the vehicle). XI
—I
CARRIER NAME Z
1 I
Dwlght481. _ ADDRESS 'O
T.
CITYlSTATAB:Ri
MOTOR CARR.ID ❑ Interstate ElIntrastate
I I T ❑ Not in Comm./Govt. Not in Comm./Other
------- --: - USDOT NO. ILCC NO. rn
XI
Source of above Z
. If Yes,Name on placard 0
4 digit UN NO. 1 digit Hazard class No. Xl
Xl
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 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
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 ❑ o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
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 DISABLING DAMAGE DAMAGE EXTENT: 9 TOWED BY/T6
DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE