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HomeMy WebLinkAbout2025-00047804 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100001011 01111 0 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003698472 u, 1 U21 3 4 1 U1 5 U2 1 U1 1 U2 1 U1 1 U2 1 1 10 U, 3 U2 1 *P 0119 INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 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$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash El AMENDED YR 202512025-00047804 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1 ® ❑ RELATED ®Y 0 N 07 24 2025 ®AM ❑YES ®NO U1 -< S LIBERTY ST Elgin05:39 _ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION IT1 FT/MI N E S W VILLA ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n ❑ Kane HIT&RUN ❑V ® N WITH VEHICLESOT, INVLD ❑ STOPPED U2 —I lgi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS O Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEOAL 0 EWES 0 uuv 0!Cy 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C) 0 2 / yr 13-UNDER CARRIAGE ©,I �:: FIRE 0 N STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14--TOTAL(ALL) DISTRACTED 0 ]$I U2 O m M 2 OTHER 4 ❑Y ®SYSNEM IN❑UNK VEH. O AT CRASH O 99-UNKNOWN 9 76.70P 3 ,Distraction Value 9 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8, it a 4 COM VEH 0 j$J 1 0 ~ ELGIN I L 60120 0 1 0 FIRST CONTACT 12 7 ; __5 *u Yes.See Sidebar U1 Z EP92837 IL 2025 E TELEPHONE IL D 0 JTHCF5C20C2035683 First Chicago Insurance C ❑Y ®N U2 m .5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Ana. Pozos ILS111599600 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER 2 ou m g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0!My 0 NCv 0 DV 9 yr 9 Toyota Corolla 1998 00-NONE 0.. Q!'-O DUE TO CRASH rg ❑ 2 0 13-UNDER CARRIAGE 10( I 2 FIRE ❑ ® U2 C c ij M 2 4 ❑Y ❑SYSTEM IN 0 ENGAGED 0 ®-OTHER 9,16-TOP 3 9 9 X i NDUNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-iI�1:,-4 COM VEH ❑ N U1 CO FIRST CONTACT 12 7 _ ._5 •• •IfYes,See Sidebar H ELGIN IL 60120 0 1 0 BF78148 IL 2025 IL D 0 4T1 BG22K1 WV364861 Direct Auto ❑Y N N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Elgin Fire 99 9 Same 027509611 BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Provena St.Joseph RESPONDER U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 4 71 ,41 l025 05 40 ®❑pM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 4 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1 C) 453. 2 ❑ 25 99 71 !41 ,025 05 41 ❑pM ❑Construction F R 3 0 $I CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ®AM ❑Maintenance U2 a ® 11 1 ARREST NAME Pozos. Reynaldo 11-902 1564000025 71 ,41 r025 05 46 ❑pM SLMT o N 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility AM 30 t 2 0 ARREST NAME 71 1 41 1025 06 20 MPM 0 Unknown work zone type U, 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME AM Workers present? ❑Y 30 1564 Rea. Desiree 301 81 r 91 ,025 09 00 DO 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 -< i- -----------; Not To Scale - combination):or ' INDICATE NORTH p0 i BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C - I - } (example:shuttle or charter bus):or b X A 3. Is desgned to carry 15 or fewer passengers and operated by a contract carrier I O j - } } } transporting employees In the course of their employment(example:employee X transporter-usually a van type vehicle or passenger car):or w i_ •:. __}----; •zs ;111 ® - } } } 4. Is used or designated to transport between 9 and 15 passengers,including the driver, C for direct compensation(example:large van used for specific purpose):or L i.____a____.l �. _ 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires D ICI placarding(example:placards will be displayed on the vehicle). XI m I�,,I _ __ -I UnRl3 _ CARRIER NAME Z ADDRESS 0I ril CITY/STATE/ZIPg - i. i. i. MOTOR CARR.ID 0 Interstate 0 Intrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other i— ----"1 - USDOT NO. ILCC NO. rTt XI Source of above z . 0 Yes II No ❑ Unknown A 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' T TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Silver Gold u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. Redmons/Impound Lot Garage 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