HomeMy WebLinkAbout2025-00052268 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets Mill III H IIlI
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003924836
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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 El$501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY El OVER 31,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 2025I 2025-00052268 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 mS CLIFTON AVE El 07:35
® ❑ RELATED ®Y 0 N 08 12 2025 ®AM YES ®NO U1 —<
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION III
FT!MI N E S W VAN ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEOAL 0 EWES 0 NIAV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
C)
0 3 /
yr 13-UNDER CARRIAGE 10.I• 2 FIRE ❑ al
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® 0 U2 0 171
F 2 8 ❑Y ❑SNE®UNK VINEH. 9 ATCRASHD 9 99-UNKNOWN 15-OTHER 9 16•TOP 3 `Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, i�6 4 COM VEH ❑ j$J 1 0
~ ELGIN I L 60123 0 1 0 FIRST CONTACT 12 7 ; _5 *II Yes.See Sidebar U1
Z 3082529B IL 2025 REAR
TELEPHONE
IL D 1 GTV2LEC7JZ296930 State Farm ❑Y ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
Villacana.Gonzalo 2173905SFP13 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 eu
p; DRIVER 0 PARKED 0 DRIVERLESS ❑ PED 0 PEDAL 0 EWES 0 NMV 0 NCv 0 DV
/2 0 0 7 Volkswagen Jetta 2011 00-NONE 11 12.._, DUE TO CRASH rg ❑ 2 x
o - 13-UNDER CARRIAGE FIRE 0 ® U2
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M 2 6 SYSTEM IN 9 ENGAGED 9 15-OTHER 016-TOP 3 X
❑Y ❑N ®UNK VEH. AT CRASH 99-UNKNOWN *Distraction value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF O I .i, 4 COM VEH ❑ ® Ut CO
F„ FIRST CONTACT 11 7 -5 •If Yes.See Sidebar C
ELGIN IL 60123 B 1 0 CB37425 IL 2026 I O C
IL D State Farm ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Lopez Morales. Melia 2117118SFP13 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (D081 (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
1 3 10 /
:A
/ / UI 2 D
/ / 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 4 8/ ,2/ /025 07 35 ®❑pM in a Work Zone? ®N DIRP co
1 1 PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 7 C)
T
0 2 ❑ 23 2 / / 0 PM ❑Construction
R 3 ❑ $I CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM 0 Maintenance U2
4 ® 11 4 ARREST NAME Villicana.Yulisa.A. 11-904-C 410000744 / / ID PM SLMT
o Nu ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
r 2 ❑ ARREST NAME AM
T / / pM ❑Unknown work zone type 25
U1
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 25
410-DeLeon.Jessica 601 9/ / 6/ /025 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
�____r____; I _ 1. Hasor more than pound (example:truck or truck/trailer
1. Has a weight rating10 000 5 � -<
s'fCdbnPAv� INDICATE NORTH combination): p0
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
t- (example:shuttle or charter bus):or 0
3. Is designed to car 15 or fewer passengers and operated a contract carrier O
- I } } } transporting employees In the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or CO
__ __ N I _ } } } 4. Is used or designated to transport between 9 and 15 passengers,including the driver, w
for direct compensation(example:large van used for specific purpose):or O
vrnst Igi r-.i_ •D
L L____a____. 1;, - _ } } } 5. Is anyvehicle used to transport anyhazardous material(HAZMAT)that requires
m
,�. am'1 placardig(example:placards will be isplayed on the vehicle). XI
CARRIER NAME Z
- _Jot , ADDRESS
T O
To Seals T.
CITY/STATE/ZIP n
- i. MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
--- --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. 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 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
White White
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE