HomeMy WebLinkAbout2025-00053250 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets Mill III H IIII
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003926451
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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 2
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 2025I 2025-00053Z5O VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 10 "I
SLADE AVE Elgin 08:07
® ❑ RELATED ®Y 0 N 08 15 2025 12,— ❑YES ®NO U1 -<
PRIVATE mo !day!yr ®PM FLOW CONDITION 1T1
FT N E S W PROSPECT BLVD COUNTY PROPERTY ❑Y ® N DOORING ❑Y #OF MOTOR 0 SLOW 6 Cl)
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑NW 0!Cy ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
0 7 /
yr 13-UNDER CARRIAGE } FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O O DISTRACTED 0 0 U2 2 M
M 5 3 SYTM❑Y ®SNE❑UNK VEH. O ATCRASHD 0 99-UUNKNOWN THER9 76.70P 3 ,Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s iL 6 4 COM VEH 0 j$J 1 0
~ ELGIN I L 60120 A 1 8 FIRST CONTACT 12 7_; _5 *II Yes.See Sidebar U1
Z NO PLATE Unknown REAR
TELEPHONE
NA Other 0 JKAKXTFCZMA021820 uninsured ❑Y ❑N U2 m
.5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 99 9 Mrauda.Walter uninsured 1 rn
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
99 0
m N DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑row 0 Ncv ❑DV
yr C
13-UNDER CARRIAGE FIRE U2
c0 ®
M 2 4 SYSTEM IN 0 ENGAGED 0 ®-OTHER O9 16-TOP 3 X
❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *OistractIon Value 9 g
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 i 6 i',. COM VEH D ® Ut CO
FIRST CONTACT 9 7 _, _5 C.)ryes.See Sidebar C
ELGIN IL 60120 0 1 0 3179347B IL 2025 Si)0
M
IL D 7 1 C6SRFFT3LN347288 State Farm ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 1169761 sfp13 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (DOBi (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
2 3 08 /
:A
/ / ut 1 D
/ / 2 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 4 08,15 l2025 08 08 ®AM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 ,,
v 2 0 28 15 08,15 ,2025 08 08 El Pm El Construction 3 >F
R O 0 gi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME
3 ❑AM 0 Maintenance U2
o ® 11 4 ARREST NAME Ramirez. Raul 11-1426.1 1564000043 08,15/2025 08 12 Igi pM ❑Utility SLMT
I$[CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME N El AM
o t 2 El ARREST NAME Ramirez. Raul 11-601 1564000044 08(15 ,2025 09 00 0 PM El Unknown work zone type U1 30
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1564-Rea. Desiree 102 09 , 16,2025 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••--, , - ; 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 -<
c ` -' -' i 0
r INDICATE NORTH combination):or .Z-1
Not To Scale BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
I - (example:shuttle or charter bus):or
N
' r r r
3. Is designed to car 15 or fewer ssfen ers and o rated a contract carrier O
} } } transporting employees In the course�of their employment(example:employee
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 N}--- ----; turw - } } } g po passen rs,includi the driver,
for direct compensation(example:large van used for specific purpose):or
L____a____. --miteI. I _ 5. Is any vehicle used to transport anyhazardous material(HAZMAT)thatrequires
armftee placarding(example:placards will be displayed on the vehicle).
IllnItIR -I
- CARRIER NAME Z
r r T 1 rill' ADDRESS 'n
V)
CITY/STATE/ZIP n
MOTOR CARR.ID 0 Interstate 0 Intrastate
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
------- --1 - USDOT NO. ILCC NO. rn
XI
Source of above z
. ❑ Yes 0 No 0 Unknown g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash?
❑ 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'; 0 Yes 0 No 2
TRAILER VIN 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Green Red
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 DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE