HomeMy WebLinkAbout2025-00054015 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500
El NOT ON SCENE(DESK REPORT)
0 AMENDED ElB Injury and/or Tow Due To Crash YR 2025512025-00054015 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 10 -11
® ❑ RELATED ®Y 0 N 08 19 2025 ®AM ❑YES 0 NO U1 -<
S STATE ST Elgin09:11
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FT!MI N E S W OAK ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 KIN 0 lacv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FOR DAMAGED AREA(S) FRO T TOWED U1 0
NAME(LAST,FIRST,M) q mo
/1 9 8 1 Honda CBR600RR 1989 00-NONE „ 12 , DUE TO CRASH ❑ EN E
13-UNDER CARRIAGE 101 2 FIRE 0IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED Er ]$I U2 2 m
M 5 4 SYSTM❑Y El NE❑UNK VEH. 0 AT CRASH 0 15-99-UNKNOWN THER9 76•TOP 3 *Distraction Value 9 ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S_iL S ii,4 COM VEH 0 ix) 1 0
F.
ELGIN IL 60120 0 1 8 FIRST CONTACT 1 7. •, *IlYes.SeeSidebar Ut
Z MCYDD165 IL 2015 REAR
TELEPHONE
IL D 0 JH2PC1908KM203493 none ❑Y ❑N U2 I—
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
Elgin Fire 99 9 Same none 2 m
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Sherman ❑Y ® N 2 X
g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 row 0 Ncv ❑DV
!1 9 6 4 Kia Motors Co�ptima 2019 00-NONE 'o,I (,- FIRE
mo yr t2 O CRASH D ® U2 C DUE 273
o 13-UNDER CARRIAGE
II
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•Top
3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN t *Distraction Value 9
POINT OF S i l( 4 COM VEH D ® Ut CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6
FIRST CONTACT 7 Q _,�_5 •ITYes,See Sidebar
Bolingbrook IL 60440 0 1 0 FQ56882 IL 2026 I 0 C
IL D 0 5XXGT4L34KG312486 Progressive ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire 99 9 Same 977017222 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(A.DDRESS)1(TELEPHONE) (EMS) (HOSPITAL)
2 3 04 /
' D
/ / 2 0
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ®Y U2 Z
N 1 ® 11 4 co
08/19 /2025 09 11 0 PM in a Work Zone? ❑N DIRP D
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1 C)
v 2 0
20 50 08,19 /2025 09 17 ❑pM El Construction
O
R 3 0 gi CITATIONS ISSUED PENDING SECTION CITATION NO. EMS ARRIVED TIME 8
z J ®AM 0 Maintenance U2
o u ® 11 4 ARREST NAME Vazquez-Montiel. Ivan 3-707 1560000065 08/19/2025 09 23 ❑pM• • El SLMT
lgl CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM
T 2 El ARREST NAME Vazquez-Montiel. Ivan 11-709-A 1560000064 08/19 /2025 09 45 M PM El Unknown work zone type U1 30
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1560-Jones. Bennett 701 10 ,07/2025 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
8.7f3tete8L 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
c ` -- -' r INDICATE NORTH combination):or —I
i 1
LBY ARROW 2 Is used or designed to transport more than 15 passengers including the driver n
1
_ (example:shuttle or charter bus):or
3. Is X
< <---- -•-•; transporting employeened to s 5 or fewer inthe course passengers
rhea emand ployment operated
xample:employee
transporter} } }
6ransportet-usually a van type vehicle or passenger car):or CD
L •:. __}. ...I. '"' - •} } 1 4. Is used or designated to transport between 9 and 15 passengers,including the driver, C
we«1 for direct compensation(example:large van used for specific purpose):or
L L____a____. l. i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). XI
r raj D
U'°'p _I
CARRIER NAME Not To Scale 1Z
ADDRESS D
. 1. L. 1.. ......: :
CITY/STATE/ZIP- MOTOR CARR.ID 0 Interstate El
I
❑ Not in Comm./Govt. 0 Not in Comm./Other
------- --1 - USDOT NO. ILCC NO. rn
XI
Source of above z
.
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' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 ❑ o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Red 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 DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE