HomeMy WebLinkAbout2025-00051902 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets lUI
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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 ❑5501-51,500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 2025I 2025-00051902 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
BLUFF CITY BLVD Elgin 09:54
® ❑ RELATED ®Y 0 N 08 10 2025 ❑AM ❑YES ®NO U1 -<
_ -COUNTY PRIVATE mo /day/yr ®PM FLOW CONDITION MFT!MI N E S W LAVOIE AVE COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR ❑SLOW 2 fA
❑ 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
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 KIN 0!CV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
0 4 /
yr 13-UNDER CARRIAGE .l FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 h O DISTRACTED 0 0 U2 al 2 M
F 2 8 ❑Y ❑SNEM®UNK VEH. 9
r AT CRASHD 9 99-UNKNOWN 9 16•TOP® ,Distraction Value ALGN =
CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 7 :il 6 �i,4 COM VEH ❑ j$J 1 0
~ ELGIN IL 60120 0 1 0 FIRST CONTACT 2 7_: --5 *IIYes.SeeSidebar U1
Z FJ34416 IL 2026 E
TELEPHONE
IL D 0 1 G 1 PC5SH8G7153564 Progressive ❑Y IlN U2 1-
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
Wallace.Joanna. L. 997577858 2 r
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 X
m E{ DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEOAL ❑EWES 0 N4v 0 i v 0 Dv
/1 9 9 9 Chevrolet Silverado 2016 00-NONE 012.._, DUE TO CRASH 0 p 2 x
0Yr 13-UNDER CARRIAGE 10 I 2 FIRE 0 ® U2 C
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M 2 8 SYSTEM IN 9 ENGAGED 9 15-OTHER 9,16-TOP 3 X
❑Y ❑N ®UNK VEH. AT CRASH 99-UNKNOWN *OistractIon Value 0
POINT OF 8 i1�I 4 COM VEH ❑ ® U1 IN
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6
FIRST CONTACT 11 7 _5 •If Yes.See Sidebar
Z Chicago IL 60652 0 1 0 3631199B IL 2026 I 0 N
Z
IL D 0 1GCVKREC5GZ113245 Geico ❑Y ®N RDEF .XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 6203868415 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER
u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
2 3 06 /
DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 1 Dia-Granillo. Emilio Wired fence 08,10 /2025 09 54 ®PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
2 ❑ 39 5 810 LAVOIE AVE ELGIN IL 60120 2 10 / / PM
0 • 0 Construction *
R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM 0 Maintenance U2
o1El 11 1 ARREST NAME Topel.Amaya.C. 11-901-A S1522-345 / / El PM SLMT
o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
r 2 ❑ ARREST NAME AM
7 / / ❑❑PM 0 Unknown work zone type 35
U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 35
1522-Velazquez. Noeli 401 269-Mendiola 09 /09,2025 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
AA 1. Has a weight rating more than 10,000 pounds(example:truck or truck/trailer -<
c ':--- -'- ' A r INDICATE NORTH combination):or -I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ } (example:shuttle or charter bus):or
X
3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
I- <.__-A-.-.J. 810?Lavye9 } } } . transporting employees In the course of their employment(example:employee X
`R0.1 , transporter-usually a van type vehicle or passenger car):or
- _ okarz i ralW - } 1} 4. Is used or designated to transport between 9 and 15 passengers,including the driver, N
; '__ - for direct compensation(example:large van used for specific purpose):or
L -a-.... - - - - - If 'Op - L I. i I L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
'e placarding(example:placards will be displayed on the vehicle). X/
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Tr CARRIER NAME Z
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ADDRESS 0
Levele9Ave , , , , , T.
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Not To Scale I CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
; _Y_._-1 - 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
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Xt
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
Blue Black
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT' 2 TOWED BY/TO.
Arties/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® Arties/Impound.Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE