HomeMy WebLinkAbout2025-00053598 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00393410
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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$1,500 ®NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 2025I 2025-00053598 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
N DUBOIS AVE El In06:30
® ❑ RELATED ❑Y ®N 08 14 2025 ❑AM ❑YES El NO U1 -<
g PRIVATE mo !day/yr ®PM FLOW CONDITION m
_
FT!MI N E S W LARKIN AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER O PARKED O DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!Cy 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
1 0 !
yr
Lopez.o ez. Ryan. I. Honda Civic 2004 00-NONE ,, 12 , OUE TO CRASH ® ❑
13-UNDERCARRIAGE 10 O 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 m
M 2 SY4 ❑Y ®SNE❑UNK VEH. O AT CRASM IN H O 99-UNKNOWN 9 76•TOP 3 `Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S_iL S ii,4 COM VEH ❑ j$J 1 0
~ ELGIN I L 60123 0 1 FIRST CONTACT 1 7_; __5 *II Yes.See Sidebar Ut
Z FB73530 IL 2025 REAR
TELEPHONE
IL D 1HGEM22134L081013 None ❑Y ign4 U2 13 . m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same none 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ❑ N 2 71
0 DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 m/v 0 i v 0 Dv
yr 13-UNDER CARRIAGE 1U 1 t2 ;,_2 FIRE ❑ ® U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER O9 16.70P 3 0 ® SPDR
❑Y ❑N DUNK VEH. AT CRASH 99-UNKNOWN *0istracii n Value 9 g
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF O I 4 COM VEH ❑ ® U1 IN
F,,, FIRST CONTACT 8 7A� .5 ••IfYes,See Sidebar C
CE78761 I L I_ 0 fp
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
KN DJ P3A52E7033897 none ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
99 9 Seymote. Paloma. M. none BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEATI (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 18 3 08,17 l2025 11 11 ®❑PM AM in a Work Zone? ®N DIRP D
co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
o"
2 ❑ 18 18 / ! ❑PM• ❑Construction *
Z ' EMS ARRIVED TIME 7
3 ❑ ]gl CITATIONS ISSUED 0PENDING SECTION CITATION NO. ❑AM ❑Maintenance U2
-a, ARREST NAME Lopez. Ryan. I. 3-707 486000245 , ! ❑PM
o u 1 ® 11 1 CITATIONS ISSUED 0PENDING TIME • ❑Utility SLMT
o NSECTION CITATION NO. ROAD CLEARANCE AM 30
t 2 ❑ ARREST NAME Lopez. Ryan. I. 6-303-A 486000244 , r 0 PM ❑Unknown work zone type U1
2 2 3 ElOFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? D Y 30
547-Hometer.William 09 ,02,2025 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••--, , / ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
r / combination):or more than pound (example:truck or truck/trailer
1. Has a weight rating10 000 5 -<
INDICATE NORTH -I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver n
/ (example:shuttle or charter bus):or
X
I. / 3. Is designed to carry15 or fewer passengers and operated a contract carrier O
`'"""A '" Leran?Aw ` Not To Scale `
} } } transporting employee in the vehicleof their employment cant(example:employee co
/ transporter-usually a van type or passenger car):or w
I. 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
1 1 / N?Dubola?Ave '
l. L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
/ thy,r — placarding(example:placards will be displayed on the vehicle). ,Zmt
—1
/ CARRIER NAME Z
Untt2 - i. ADDRESS D
rn
/ O
CITY/STATE/ZIP C)
_ MOTOR CARR.ID 0 Interstate 0 Intrastate
/ ❑ Not in Comm./Govt. 0 Not in Comm./Other 00
‘I. - --4. 1 - USDOT NO. ILCC NO. m
m
XI
Source of above z
. MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No Z
Form Number 0
m
Xl
IDOT PERMIT NO. WIDELOAD-; ❑Yes 0 No 2
TRAILER VIN 1 m
to
LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 0 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Blue Beige
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 3 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