HomeMy WebLinkAbout2025-00047716 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 1011011001 0110111 1011011
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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 1
VEHICLE/PROPERTY El OVER$1,500 ®NOT ON SCENE(DESK REPORT)
0 AMENDED ElB Injury and f or Tow Due To Crash YR 2025512025-00047716 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED ' V 0 N 07 23 2025 DAM ❑YES ®NO U1 -<
E CHICAGO ST Elgin05:30
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W CENTER ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW Cl)
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
Hernandez.Jasmin 0 4 /
yr 13-UNDER CARRIAGE IE
101 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 m
F 2 SY 15-OTHER
4 ❑Y ®SNE❑UNK VEH. 0 AT CRASH M IN D 0 99-UNKNOWN 9 76•TOP 3 *Distraction Value 9 ALGN =
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r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s,_iL B �i 4 COM VEH 0 j$J 1 0
F• Elgin IL 60120 0 1 0 FIRST CONTACT 1 7 ; __5 *IIYes.SeeSidebar Ut
Z 9 Z249679 IL 2025 REAR
TELEPHONE
IL D 5YFBU4EE2DP172440 Horace Mann ❑Y Igl N U2 m
IS EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 65000009980102 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 2 0
0 DRIVER ❑ PARKED 0 DRIVERLESS DA PED ❑PEDAL 0 EWES 0 N4y 0
yr 00-NONE N_ 12 0.,. DUE TO CRASH 0 ® 77
I' 13-UNDER CARRIAGE 10 2 FIRE 0 El U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 916•TOP 3 0 El SPDR n
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istraellon Value POINT OF 8 4 9 7
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT I Y ::-S CIO e1sVEH •Sidebar❑ ® U1
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0 REAR 0,
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
NIA ❑y ❑N RDEF73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
1 50 9 NIA BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
RESPIDYD❑ N NDER U1 =
(UNIT) (SEAT) (008) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 12 1 07,23 l2025 06 32 ®PM in a Work Zone? ®N DIRP co
I I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
;, 2 ❑ 15 18
! 1 0 PM• ❑Construction *
Z3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2
-a ARREST NAME / / ID '
o u ® 12 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SIMT
,
35
ARRESTNAMEAM
7t 2 ❑ ❑❑PM ❑Unknown work zone type U1
/ 1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME y
2 2 3 ❑ - ❑AM Workers present? ❑
560-Martirez.Samantha 1ot r 1 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 -<
` ` -' -' 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
I 3. Is desgned to carry 15 or fewer passengers and operated a contract carrier O
i. <•----A----1 I
1. 1- 1- transporting employees In the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or CO
C
L L.___a_ . I 4., Isusedordesi natedtotrans rtbetween9e nd15 ge ng w} } } g Po ssen rs,includi [he driver,
for direct compensation(example:large van used fors cific purpose):or O
—I - . . 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). ,Zmt
m.
fiuTr. - -- —ICARRIER NAME Z
ADDRESS 0
Nor 7o scars l w
CITY/STATE/ZIP 0
0
MOTOR CARR.ID 0 Interstate 0 Intrastate
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
----------1 - USDOT NO. ILCC NO. m
73
Source of above z
. MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No Z
Form Number 0
m
Xl
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
to
LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 0 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 0 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 DUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO.
DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE