HomeMy WebLinkAbout2025-00050011 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
I011011001 I
1110100100
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003912,23
u, 1 U21 3 4 1 U1 1 U2 1 U1 1 U2 1 U1 1 U2 1 1 10 U, 3 U2 1 *P 0119
INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
❑AMENDED YR 202512025-00050011 VEHT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 —n
ST CHARLES ST Elgin 03:47
® ❑ RELATED ®Y 0 N 08 02 2025 ❑AM ❑YES ®NO U1 -<
_ _ PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT l MI N E S W BLUFF CITY BLVD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR El SLOW 1 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EOUES 0 Nuv 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
FOR DAMAGEDAREA(S) FROr4r TOWED U1 Q
Martinez Romero. Lezlie.J. 1 1 /
yr 13-UNDER CARRIAGE IE
10 •�. 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 02 m
F 2 4 SYTM❑Y ®SNE❑UNK VEH. 0 AT CRASH 99-UUNKNOWN THER9 16•TrOPI� *Distraction Value I ALGN
-
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 7 i, a �i,4 COM VEH ❑ Ea 1 0
~ ELGIN IL 60120 0 1 0 FIRST CONTACT 3 7_; _-5 *IfYes.SeeSidebar U1
Z EZ75562 IL 2025 E
TELEPHONE
IL D 0 SHHFK7H41JU432229 Safeway Insurance Company ❑Y Il N U2 m
.5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Mendez Aranda. Francisco.J. 3575527ILPP077 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER
2 ou
m g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL ❑EWES 0 row 0 NOV 0 Dv
1 9 5 7 Nissan Pathfinder 2017 00-NONE ,�_"j Q1:-_, DUETOCRASH rg ❑ 2 x
0 Yr 13-UNDER CARRIAGE 1a) I. z FIRE ❑ ® U2 C
c
M 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X
0 Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 1 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s_i S 1� 4 COM VEH ❑ ® U1 W
FIRST CONTACT 12 7A 6 L':5 •It Yes.See Sidebar C
z SOUTH ELGIN IL 60177 0 1 0 Z218202 IL 2025 I 0 Si)
IL D 0 5N1 DR2MM1 HC903246 American Select Insurance ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same WNP130155W BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER
u1 =
(UNIT) (SEAT) (DOB1 (SEX) (SAFT) (AIR) (WI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 6 07 / M 2 3 0 1 0
m
/ / #OCCS D
/ / UI2 mm
/ / 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 08,02 ,2025 03 47 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 2
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
v 2 2 2 08,02 ,2025 03 58 El Pm ❑Construction >F
R 3 0 ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
z J ❑AM ❑Maintenance U2
o ® 11 1 ARREST NAME Martinez Romero. Lezlie.J. 11-801-B 1511337 08,02 r2025 04 02 Igi pM' 0 Utility SLMT
o N 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME0 Am
r 2 0 ARREST NAME 08 t 02 ,2025 04 40 0 PM 0 Unknown work zone type U1 30
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1511-Ayala. Roberto 400 08 ,02,2025 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
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
i- }--__r-_--; I ` combination):or —I
INDICATE NORTH p1
i I I BY ARROW 2 Is used ordesi nedtotran ortmorethan15 C g sp passengers including the driver C
} r r (example:shuttle or charter bus):or 0
3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
}. A.---1
} } } transporting employees In the course of their employment(example:employee X
i transporter-usually a van type vehicle or passenger car):or w
- -.
4. Is used or designated to transport between 9 and 15 passengers,including rCjt
i. �-----;- --; - } } } g po passen rs,indudi the driver,
r �-- for direct compensation(example:large van used for specific purpose):or
�. O
L h i I L i i ._ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). ;p
— — — — — —
-1
CARRIER NAME Z
A.
ADDRESS 0ewmapaera Ni U)
0
Not To Scale CITY/STATE/ZIPg
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other
; _Y_ _-1 - USDOT NO. ILCC NO. 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. 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?El❑ Yes II 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 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
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 White
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE