HomeMy WebLinkAbout2025-00051155 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
011011001 I 111000 III
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003915880
u, 1 u2 1 1 1 U116 U2 1 u, 1 U2 U, 1 u2 1 1 9 U1 1 U221 *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 1
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 202512025-00051155 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
® ❑ RELATED PRIVATE ❑Y ®N 08 07 2025 ®AM ❑YES ®NO U1
S EDISON AVE Elgin mo /day/yr 11.11 ❑PM FLOW CONDITION m
_
10(� COUNTY PROPERTY ❑Y 2�l N DOORING Ely #OF MOTOR 0 SLOW 1 (n
® 1C.'J/MI O E S W Shuler St WITH VEHICLES INVLD 0 STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑V ® N PEDALCYCLIST®N ® FREE FLOW # LNS 0
18:DRIVER 0 PARKED 0 DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 NW 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FOR DAMAGEDAREA(S) Mao TOWED U1 O
NAME(LAST,FIRST,M) Unknown. Unknown mo yr Chevrolet Traverse 2016 00-NONE
13-UNDER CARRIAGE IE
1 DUE TO CRASH ® ❑
1t. 12• Q E
FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED 0 0 U2 2 m
M 2 4 SYTM❑Y ®SNE❑UNK VEH. O ATCRASHD 0 15-99-UUNKNOWN THER9 16•TIDP 3 `Distraction Value 9 ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s iI s V4 COM VEH 0 El 1 0
~ ELGIN IL 60123 0 1 0 FIRST CONTACT 1 7_; __5 *IIYes.See Sidebar U1
Z FC20778 IL 2026 E
TELEPHONE
IL D 1 G N KVH KD7GJ 188133 Talro Insurance Agency ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
Other Walls, Darrel, L. I LAA-1040505 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 73
0 DRIVER X. PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0
yr 10.j t2 c, E FIRE ❑ ® U2 2 C
o 13-UNDER CARRIAGE
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN 0 ENGAGED 0 15-OTHER 911,6•TOP3 0 ® SPDR n
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraetlon Value O -
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF O' ii 4 COM VEH ❑ ® Ut W
F,,, FIRST CONTACT 7 Q B l':s •If Yes,See Sidebar
FA92830 IL 2025 REAR
0 N
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
2HGFE4F8XSH306140 Geico ❑Y ®N RDEF M
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Vazquez. Ma, R. 4308741745 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)(TELEPHONE) (EMS) (HOSPITAL)
1 2 06 / F 2 4 0 1 0
m
/ / #OCCS D
7/
/ / UI 2 m
/ / 0 O
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2Z
N 1 ® 18 1 08,07 /2025 11 11 ®❑AM in a Work Zone? ®N DIRP co
I I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
2 ❑ 28 99
N 1 3 0 CITATIONS ISSUED 0 PENDING + / ❑PM• El Construction >E
SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
-a, ARREST NAME / / El PM '
S' N ® 11 1 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT
30
t 2 ARREST NAME AM
7 El / ❑❑PM 0 Unknown work zone type U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1547-Steele,Justin 601 09 /02,2025 09 00 ❑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----r••--, , A CMV is defined as any motor vehicle used to transport passengers or property and: Z
i- �____r____; I DNt2 _ combination):or more than pounds(example:truck ortruckrtrarler 1. Has a weight rating10 000 -<
, INDICATE NORTH -I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
Not To Sca/eJ I _ r r r (example:shuttle or charter bus):or 0
me�awn.•
L A — 3. Is desgned to carry 15 or fewer passengers and operated a contract carrier O
- } } } transporting employees In the course of their employment(example:employee
II.
transporter-usually a van type vehicle or passenger car):orco
C
L -----}----; tLr,,,nn I } 1.} 4. Is used or designated to transport between 9 and 15passengers,including the driver.
I I I I �$9E'dYon4/0.vr♦) for direct compensation(example:large van used fors specific purpose):or
71
I I
i. i t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
a I placarding(example:placards will be displayed on the vehicle).
m
XI
CARRIER NAME Z
ADDRESS 0
r' 1, CITY/STATE/ZIP o
ff 11
J ll - MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. Not in Comm./Other
____ _ __. USDOT NO. ILCC NO. m
XI
Source of above z
. 0 Yes 0 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
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
Black Red
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Other/Unknown SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Aides/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE