HomeMy WebLinkAbout2025-00052912 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets Mill III H IIII
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0111101 HIll III EMMMMM
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003924864
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 2025I 2025-00052912 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �l
KI M BALL ST Elgin 02:23
® ❑ RELATED ®Y 0 N 08 14 2025 ❑AM ❑YES ®NO U1 -<
_ _ g PRIVATE mo !day!yr ®PM FLOW CONDITION MFTlMI N E S W DOUGLASAVE COUNTY PROPERTY ❑ ® N DOORING® DOORING ❑y #OF MOTOR 0 SLOW 15 u)
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 NIA/ 0!CV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FOR DAMAGEDAREA(S) FRO TOWED U1 Q
l
1 2 /
yr q 12 -
13-UNDER CARRIAGE y 2 EN E
FIRE 0 IE
10
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ]$I U2 2 rn
F 2 4 SYTM❑Y ®SNE❑UNK VEH. 0 AT CRASH 0 99-U 15- NKNOWN THER9 16•TOP® ,Distraction Value ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s ij 6 �I COM VEH 0 0 1 C)
F.
ELGIN I N I L 60123 0 1 0 FIRST CONTACT 3 7_: R-O •II Yes.See Sidebar U1 0
Z FG79550 IL 2025
TELEPHONE
IL D 0 1GNALCEKOEZ108541 n/a ❑Y ❑N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same n/a 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y ® N 2 XI
p; DRIVER ❑ PARKED 0 DRIVERLESS ❑ FED ❑PEDAL ❑EWES ❑m v 0 i v ❑Dv
!2 0 0 2 FR
Jeep(after 196;;i)ind Cherokee 2014 00-NONE „ 12 _, DUE TO CRASH 0 2 x
Ti Yr 13-UNDER CARRIAGE FIRE 0 ® U2
M 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER O9 16-TOP 3 X
0 Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN `Oistracton Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 I_d',.4 C.OM VEH ❑ ® Ut CO
F„ FIRST CONTACT 11 7 _, _5 •If Yes.See Sidebar C
Z ELGIN IL 60123 0 1 0 ET24052 IL 2024 I 0 Si)M
IL D 0 1 C4RJ FBG3EC566497 n/a ❑Y ❑N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same n)a BAc E
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)
2 4 03 /
:A
/ / UI 1 D
/ / 3 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 08/14 /2025 02 23 ®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
0 2 0 04 99 / / ❑PM ❑Construction
1
R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM 0 Maintenance U2
-a, ARREST NAME Gamboa Tarazona. Ingrid. M. 3-707 1528-000294 / / El PM SLMT
ou El 11 1 ISI CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El AM• El Utility
t 2 El ARREST NAME Gamboa Tarazona. Ingrid. M. 11-709-A W1528-000297 08/14 /2025 02 30 ®PM El Unknown work zone type U1 30
2 2 3 El OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑y 25
1528-Rivera. Kevin 102 09 /22/2025 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••--, , I 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 -' r INDICATE NORTH combination):or .Z-1
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 tocarry 15 or fewer passengers and operated a contract carrier 0
5
es pa g pe
- } } } transporting employees in the course of their employment(example:employee � 73
transporter-usually a van type vehicle or passenger car):or w
L 4. Is used or designated to transport between 9 and 15 passengers,including C}--- ----; - } } } g po passen rs,includi the driver,
for direct compensation(example:large van used for specific purpose):or
._ -a - t i . I 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
-u
J ` ur,� placarding(example:placards will be displayed on the vehicle). XIunllasa
CARRIER NAME Z
ADDRESS 0
w
Not To Scene I Kfrnholltat n
CITY/STATE/ZIP 0
MOTOR CARR.ID 0 Interstate ElIntrastate
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
;....Y___. USDOT NO. ILCC NO. m
XI
Source of above z
IDOT PERMIT NO. WIDELOAD-; ❑Yes 0 No =
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 Black
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE