HomeMy WebLinkAbout2025-00049743 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 1011011001 l I 1111 NilDRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003912:56
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INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 7
VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and for Tow Due To Crash YR 2025I 2025-00049743 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
504 WAVERLY DR El03:34
® ❑ RELATED ❑Y ®N 08 01 2025 12,— ❑YES ®NO U1 —<
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ FT/MI NESW Cook HIT&RUN ®Y ❑ N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 --1
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER O PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C)
FOR DAMAGEDAREA(S) FROPtf TOWED U1 O
NAME(LAST,FIRST,M)
Ortizmo /1 9 6 5 Ford Focus 2008 00-NONE it 12 , DUE TO CRASH 0 13-UNDER CARRIAGE .( FIRE ❑ I23
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 1U O DISTRACTED 0 14 U2 0 m
M 9 SY 15-OTHER
9 ❑Y ®SNE❑UNK VEH. 0 AT CRASH M IN D 0 99-UNKNOWN 9 16•TOP 3 ,Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ ;ij S 1,-._4 COM VEH 0 0 1
H 1 ELGIN IL 60120 0 9 0 EF71615 IL FIRST CONTACT 6 7 ;1 _s Yes.See Sidebar U1 0
Z E
TELEPHONE
IL D 1FAHP35N48W147490 Magnum Insurance ❑Y ®N U2 m
IS EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Martinez-Roque. Petra ILP2745392 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
99 0
❑ DRIVER X. PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0
yr Chevrolet Malibu 2014 00-NONE ,�_O'' t2..-_, El El
TO CRASH 0 ® 173
I' 13-UNDERCARRIAGE 9( 2 FIRE U2 C
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR 0
SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 0
a 0 Y NJ 0 UNK VEH. AT CRASH 99-UNKNOWN `Oistracton Value
POINT OF 8 4 Ut
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR ��',_ COM VEH ❑ ® CO
FIRST CONTACT 9 7 -s •• •If Yes,See Sidebar
H V861340 IL 2025 I 0 N
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
1 G11 B5SL1 EF228539 None ❑Y ❑N RDEF XJ
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same None BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
ElYRESPONDER
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Y
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) OM (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
0 O
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 18 5 08,01 l2025 03 34 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
o"
2 28 99 + / ❑PM• ❑Construction *
Z 3 0 El CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
o ® 11 5 ARREST NAME Ortiz Baez. Mario.A. 11-404 S1552000145 , ! El PM SLMT
o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
05
t 2 0 ARREST NAME AM
T 1 r ❑❑PM ❑Unknown work zone type U1
%
2 2 3 IDOFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 15
1552-Thompson.Ahmad Rashad 201 09 , 16,2025 01 30 ®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
unna z
'n.'' 1 s weight rating more than 10,000 pounds(example:truck or truck trailer
A -� combinatio ):or C
�----r----, - r
INDICATE NORTH
r BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i I iI I f - (example:shuttle or charter bus):or
r 3. Is designed to carry15 or fewer passengers and operated a contract carrier O
rr� X
< <.___A. _.. 1 } transporting employees In the course of their employment(example:employee X
IMP r• } F } transppoorterg-usually a van type vehicle or passenger car): r co
:- :- --}----; W'' - } } 1 •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
O
' L___-a..... __ _ ,. - L i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). m
Not To ScaleXI
a CARRIER NAME Z
ADDRESS O
(IIII;:;;-I;)
C
NCITY/STATE/ZIP C)
_ i. MOTOR CARR.ID 0 Interstate ❑ Intrastate
' ❑ Not in Comm./Govt. ❑ Not in Comm./Other 00
-"-------1 USDOT NO. ILCC NO. C
m
XI
Source of above z
. —I
Were HAZMAT placards on vehicle? 0 Yes 0 No =
If Yes,Name on placard O
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 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 VIM 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
Gray White
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 DUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE