HomeMy WebLinkAbout2025-00046697 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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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 El$501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 2025I 2025-00046697 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH *7
® ❑ RELATED ®Y 0 N 07 19 2025 ❑AM ❑YES ®NO U1
WAVERLY DR Elgin 04:06
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W SUMMIT ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 co
❑ Cook HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
0 DRIVER ❑ PARKED ❑DRIVERLESS PED ❑PEDAL 0 EDVES 0 Nuv 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C)
FOR DAMAGED AREA(S) FRONT TOWED U1 Q
Martinez Araujo. Ignacia 0 2 /
yr 13-UNDER CARRIAGE 101 ! 2 FIRE ❑ 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ ❑ U2 0 m
F 1 3 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 _
El N ❑UNK VEH. AT CRASH 99-UNKNOWN a 4 `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 �i COM VEH 0 0 n
I . FIRST CONTACT 15 7 ;—, _5 *it Yes.See Sidebar U1 O
Z Elgin IL 60120 B 1 0 REAR
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 -0
( 0 ❑Y ❑N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 2 52 2 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER AA
St.Alexius Medical Center ❑Y ❑ N 0
N DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PE0AL 0 EWES 0 row
yr 12 ,_ C
o 13-UNDER CARRIAGE 10 i 2 FIRE ❑ ® U2 C
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y NJ El UNK VEH. AT CRASH 99-UNKNOWN *0istracton Value 9
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-it 6 Il, COM VEH ❑ ® U1 CO
FIRST CONTACT 1 Y _, _5 •(ryes,See SidebarC
= ELGIN IL 60120 0 1 0 BW97220 IL 2026 REAR 0
IL D 0 7FARW1 H58KE021621 AARP ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire 2 52 2 Same 55100484044 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (DOB1 (SEX) {SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
2 3 05 /
7/
/ / UI ' D
/ / 2 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 CD 11 4 71 ,91 ,025 04 06 ®PM in a Work Zone? NJ DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES Check one below:
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AMU1
o", 2 2 18 71 ,91 ,025 04 07 PM
1 ® • ❑Construction
Z 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
-a ARREST NAME 71 ,91 ,025 04 09 ®PM
1 1 2 4 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME
Utilit SLMT
o, N ® 0 y
AMU1 0
T 2 El ®ARREST NAME 7/ (9/ 1025 04 24 PM 0 Unknown work zone type
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ 1542-Chase. Ethan 202 - ( 1 ❑❑AM Workers present? ®N U2 30
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 truckrtrailer -<
c ` --I -' r INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ (example:shuttle or charter bus):or 0
y Not �,,J 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
1 y transporter-usually a van type vehicle or passenger car):or w
4. Is used or designated to transport between 9 and 15 passengers,including wwjt
i. ---- ----; - } } } g po passen rs,includi the driver,
for direct compensation(example:large van used for specific purpose):or O
L L____a____� - t i t t .. 5. Isanytcvoe used to transport any hazardous material(HAZMAT)thatrequires
J •u
�\y 0 j placarding(example:placards will be displayed on the vehicle). M
r CARRIER NAME Z
-1
w Iipl ADDRESS D
rn
C)
CITY/STATE/ZIP g
_ i. i. i. i. 4. MOTOR CARR.ID 0 Interstate 0 Intrastate
0
I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other
--- --1 - USDOT NO. ILCC NO. m
XI
Source of above z
. ❑ Yes 0 No 0 Unknown g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash? A
El Yes No ❑ 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
Xl
IDOT PERMIT NO. WIDELOAD'; 0 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 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Silver
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 DUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 0 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE