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HomeMy WebLinkAbout2025-00051373 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 I011011001 I Ill DIII 00 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY xoo39i7282 u, 1 U21 2 4 1 U1 2 U2 1 U, 1 1_12 1 U, 1 U2 1 1 15 U1 1 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 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 14 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash 0 AMENDED YR 2025I 2025-00051373 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn ® ❑ RELATED ®Y 0 N 08 08 2025 ®AM ❑YES ®NO U1 RAYMOND ST Elgin 11:35 _ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION ill FT!MI N E S W BENT ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0 (g3 DRIVER ❑ 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 r4T TOWED U1 0 NAME(LAST,FIRST,M) Salazar. Elsa mo Chevrolet Tahoe 2000 00-NONE 11_ (0171 DUE TO CRASH ❑ VI 13-UNDER CARRIAGE ) 0 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 0 THERDISTRACTED 0 0U2 0 171 F 2 4 SYTM❑Y ®SNE❑UNK VEH. 0 AT CRASH 0 15-99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF T_iL 6 I,.4 COM VEH 0 Ig! 1 0 ~ ELGIN I L 60120 0 1 0 FIRST CONTACT 1 7_; __5 *II Yes.See Sidebar U1 Z EW81419 IL 2025 REAR TELEPHONE IL D 0 1 G N EK13T7YJ 157792 Kemper ❑Y J N U2 I' in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Rocha Olaguez. Maria.A. 12RA000064043 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 eu x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 iiuv 0 N v 0 Dv /1 9 8 5 Honda CRV 2013 00-NONE O z -_, DUE TO CRASH ❑ 2 0 13-UNDER CARRIAGE 9 I ©1. 2 FIRE ❑ ® U2 C c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 X ❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istraglon Value 9 0 POINT OF 8 i1�I" 4 COM VEH ❑ ® U1 W N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6 FIRST CONTACT 11 7 -5 •If Yes.See Sidebar = EAST DUNDEE IL 60118 0 1 0 S416724 IL 2026 IL D 0 5J6RM4H32DL086198 State Farm ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X 99 9 Same 0970803-SFP-13 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER u1 = (UNIT) (SEAT) (DOBi (SEX) (SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 1 6 01 / / / UI 3 :A D / / 1 0 U EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur ❑Y U2 Z N 1 ® 11 4 81 ,12 /25 11 35 ❑PM in a Work Zone? ®N DIRP D co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 O 2 ❑ 14 23 / / ❑PM ❑Construction * Z 3 ❑ Ii CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 o 1 ® 11 4 ARREST NAME Salazar. Elsa 3-414 1540-W307 / / El PM SLMT • ISI CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME p N El AM• El Utility 35 t 2 ❑ ARREST NAME Salazar. Elsa 11-1204-B 1540-305 8/ //2 /25 12 30 0 PM ❑Unknown work zone type U1 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 35 1540-Allah. Muhammad 401 91 , 12 /25 01 30 El NI ®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 Raymond?St 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 } INDICATE NORTH combination):or -1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C _ } (example:shuttle or charter bus):or L A I } 3. Is designed to carry 15 or fewer passengers and operated a contract carrier 0 } } • transporting employees in the course of their employment(example:employee X y a van type vehicle or L ...l. I ♦_ 42lsuosedordrter- esllnatedto transport between9a dr15passengers,includingthedriver, C ' ` } } for direct compensation(examp large van used for speific purose):or 0 ` h-. ..i.. .I. - t i. } 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m von— 1— Unh t ® BereSt placarding(example:placards will be displayed on the vehicle). a) r NM a '" v;�!l CARRIER NAME Z ADDRESS 1i ,► rn I CITY/STATE/ZIPo I I N MOTOR CARR.ID 0 Interstate 0 Intrastate I I T I Not TO Scale i 0 Not in Comm./Govt. 0 Not in Comm./Other 00 i 1111 ® - USDOT NO. ILCC NO. m XI Source of above z . If Yes,Name on placard 0 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? 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 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 Gold Black u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 3 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/Owners Residence VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE