HomeMy WebLinkAbout2025-00052375 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 011011001 011
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X403924838
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INVESTIGATING AGENCY DAMAGE TO ANY ❑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 1
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) El B Injury and f or Tow Due To Crash
El AMENDED
YR 2025I 2025-00052375 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 7
S MCLEAN BLVD Elgin02:21
® ❑ RELATED ®Y 0 N 08 12 2025 12,— ❑YES El NO U1 -<
PRIVATE mo !day/yr ®PM FLOW CONDITION M_
FT!MI N E S W ERIE ST COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 1 cn
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EDUCE ❑uuv ❑!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
FOR DAMAGEDAREA(S) FROf4r TOWED U1 O
Ramirez.Ya aira 0 3 /
yr 13-UNDER CARRIAGE al
10 �. 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® 0 U2 4 M
F 2 4 ❑Y ®SYSNEM❑UNK VEH. 0 AT CRASH 0 99-UUTHER NKNOWN 9 16•TOP03 ,Distraction Value 9 ALGN
-
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s ij B �I COM VEH 0 j$J 1 C)
H 1- Elgin I L 60123 0 1 0 FN85746 I L 2025 FIRST CONTACT 4 Y ;1 _Q =Yves.See Sidebar Ut
ZREAR
7 TELEPHONE
MS D 0 3VWF17AT9FM638663 Unkown ®Y ❑N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Sandoval Serrano.Victor.G. Unknown 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 7]
p; DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 i uv 0 i v 0 DV
!1 9 9 1 Honda Accord 2011 00-NONE O' Q!'O DUE TO CRASH rg ❑ 2 x
o 13-UNDER CARRIAGE 10( 12 FIRE ❑ ® U2 C
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3
❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distracion Value 9 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s-iI�1:, 4 COM VEH ❑ ® U1 CO
FIRST CONTACT 12 7�_, .5 •(ryes.See Sidebar
ELGIN IL 60123 0 1 0 Z868338 IL 2025 I 4 CC/)
IL D 0 1 HGCS1 B35BA004273 State Farm ❑Y ®N RDEF M
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Shyan. Lauren. M. 2117640-SFP-13 BAG E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOE) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((A.DDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 3 08 / F 2 4 0 1 0
m
/ / #OCCS D
77
/ / UI 2 D
/ / 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2Z
N 1 ® 11 4 08,12 12025 02 37 ®pm in a Work Zone? ®N DIRP co
1 t PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 3 0
T
0
2 ❑ 2 28 I 1 ❑PM• ❑Construction
Z3 0 I!!I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 1
-a, ARREST NAME Ramirez.Yajaira 11-601-Ax 1525000713 1 I ❑PM SLMT
o U 1 Ell 4 CITATIONS ISSUED 0 PENDING Utility
o N SECTION CITATION NO. ROAD CLEARANCE TIME AM• El
r 2 ElARREST NAME Ramirez.Yajaira 3-707 1525000711 081 12 12025 03 32 ®PM 0 Unknown work zone type U1 35
2 2 3 ID ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 35
1525-NavE.Oscar 601 09 1 23,2025 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
0 ADDITIONAL UNITS FORMS.
r ----r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and:
Not To Scale I 1. Has a weight rating more than 10,000 pounds(example:truck or truck/trailer
` ` --I -' r INDICATE NORTH combination):or A
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i - } (example:shuttle or charter bus):or
X
L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
} } } transporting employees in the course of their employment(example:employee P3
transporter-usually a van type vehicle or passenger car):or w
L L.___a__ 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or 0
L L____a____. L i L i 5. Is anyvehicle used to transport any hazardous material(HAZMAT)thatrequires 'D
rn
placarding(example:placards will be displayed on the vehicle). ;p
3v
j i CARRIER NAME Z
*y _ - ADDRESS D
r— Eria?St
Unit 2 CITY/STATE/ZIP 0
- i. i. i. i. 4. MOTOR CARR.ID 0 Interstate 0 Intrastate 5
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
' -Y- --• - USDOT NO. ILCC NO. m
PCI
Source of above z
. own tank)? 0 Yes 0 No 0 Unknown D
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes 0 No 0 Unknown g
Did Carrier Safety Regulations I/ICS)violation contribute to the crash?❑ Yes IQNo El Unknown Unknown 0
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' m
TRAILER 1 ❑ ❑ 0 z
ri
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Black Black
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