HomeMy WebLinkAbout2025-00054144 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003928605
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 15
VEHICLE/PROPERTY ElOVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 202512025-00054144 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
VILLA ST Elgin® ❑ RELATED ®Y 0 N 08 19 2025 03:49 ❑AM YES ®NO U1
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION RIFT!MI N E S W SADLER AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR NI SLOW 16 '
❑ Cook 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 EWES 0 uuv 0 wcv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 02 C)
1 0 /
Toyota Camry 2018 00-NONE
13-UNDER CARRIAGE „_' 0i0 DUE TOCRASH ® ❑
FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 0 DISTRACTED 0 0 U2 02 rn
M 2 SYTM 4 ❑Y ®SNE DUNK VEH. 0 AT CRASH 0 15-99-UNKNOWN THER9 16•TOP 3 *Distraction Value 9 ALGN
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r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 7._iL a ii,4 COM VEH 0 Ea 1 0
I .
ELGIN IL 60120 0 1 FIRST CONTACT I ; __5 *IIYes.See Sidebar U1
Z CM94725 IL 2026 REAR
TELEPHONE
IL D 4T1 B11 H K4J U046602 Farmers ❑Y ®N U2 13 , m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
co
99 9 Perez.Juan 546882737 1 r
"o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER
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p; DRIVER ❑ PARKED 0 DRIVERLESS ❑ PEO 0 PEDAL 0 EWES 0 NMv 0 KCV 0 DV
!2 0 y0r 6 Other Other 00-NONE O"I Ql-O DUE TO CRASH ❑ 2
.ia'Po 13-UNDER CARRIAGE 10( I 2 FIRE ❑ ® U2 C
M 1 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y NJ N DUNK VEH. AT CRASH 99-UNKNOWN `Distracion Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s-..,�.I,_4 COM VEH ❑ ® U1 CO
FIRST CONTACT 12 7 1.5 •If Yes.See Sidebar
4 ELGIN IL 60120 B 1 0 NIA IL 2025 I 0 C
IL D L698YGJL38MC11908 NIA ❑Y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER I X
Elgin Fire 99 9 Same NIA BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Provena St.Joseph RESPONDER u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
1 3 12 / F 2 4 0 1 0
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 4 08,19 ,2025 03 49 ®pm in a Work Zone? ®N DIRP co
1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 5 C)
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2 ❑ 2 99 , r ❑PM• ❑Construction
4
R3 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME
❑AM ❑Maintenance U2
o ® 11 4 ARREST NAME Perez.Juan.A. 11-901 1506-428 / / ID PM SLMT
u •
MI CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' El Utility
o N DI AM 30
t 2 El ARREST NAME Sandoval.Alex 11.45.030 C1506-15 , r PM ❑Unknown work zone type U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1506-Nunez. Maria 401 09 ,09,2025 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 -<
r INDICATE NORTH combination):or P3
Not To Scale BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
vluAYST '- " "- - } (example:shuttle or charter bus):or
X
L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
} } } transporting employees in the course of their employment(example:employee X
y a van type
< <.___a____. — -- transporter sedord�llnatedtotransehrtbetweeicle or n9andr15r) ssen rs,includingthedriver, N
I C OD I. } } for direct compensation(example:large van used for specific purpose):or
L L--_-a - z ■ t I. } L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
� placarding(example:placards will be displayed on the vehicle). XI
7 I uNiT1 CARRIER NAME Z
- ADDRESS 0
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CITY/STATE/ZIP n
g
- MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
�I. --- --1 - USDOT NO. ILCC NO. rn
XI
Source of above Z
. ❑ 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'; ❑Yes 0 No 2
TRAILER VIN 1 m
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LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Gray 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