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HomeMy WebLinkAbout2025-00055324 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 6 Sheets 01111101111 011011001 I0fl II I�� 1000 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0G3934023 u, 1 U210 1 1 1 U116 U2 1 u, 1 1_12 8 u, 1 U2 1 5 9 u, 1 U221 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash 0 AMENDED YR 202512025-00055324 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 :l ® ❑ RELATED ❑Y ®N 08 24 2025 IgIAM ❑YES ®NO U1 -< 470 ADDISON ST Elgin04:35 _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m COUNTY PROPERTY ❑Y 21 N DOORING ❑y #OF MOTOR IR SLOW 1 (n ❑ FT/MI NESW Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS O g DRIVER t] PARKED O DRIVERLESS 0 PED CI PEDAL 0 EWES 0 NUV 0 lacv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n 0 3 ! yr 13-UNDER CARRIAGE ©' O- FIRE ❑ tg) STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O 'O DISTRACTED 0 0 U2 2 m F 2 4 El ®SNE❑LINK VEH. 0 AT CRASH IN ENGAGED0 99-UUNKNOWN 016 3 `Distraction Value 7 ALGN = r L 6 COM VEH 0 El 1 O CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6,_i 4 ELGIN I N I L 601 20 0 1 0 FIRST CONTACT 12 7 ; _--5 *II Yes.See Sidebar U1 Z DE94122 IL 2025 • E TELEPHONE IL D 1N4AA6AP4HC44737 NIA ®Y ❑N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Elgin Fire 99 9 FIGUEROA ORTIZ.OSCAR. L. NIA 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 73 a DRIVER I} PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NO CIRCLE NUMBER(S) U1 V ❑NCV 0 DV yrXI .cio 13-UNDER CARRIAGE C 10;I c. 2 FIRE ❑ El U2 c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN ENGAGED 15-OTHER 9.16-TOP S ❑ El SPDR n ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istrac on Value 9 9 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF O i"O I COM VEH El El U1 W F,, O7 �, =L"_i s- •If Yes.See Sidebar• EL18916 IL 2025 0 N M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 1 FAH P28137G 113696 Bristol West ❑Y (EN RDEF 7) EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 = 99 9 Garnica.Jaqueline.G. G01571696102 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (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 1 08!24 l2025 04 35 ®❑AM in a Work Zone? ®N DIRP D I t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1 C) v 2 ❑ 41 28 08,24 l2025 04 39 ❑PM ❑Construction >F R O 0 ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 J ®AM ❑Maintenance U2 o1 ® 11 1 ARREST NAME Figueroa. Linda. K. 11-502.15- 1550-00136 08!24 l2025 04 45 ❑pM' 0 Utility SLMT ljg CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME o N AM t 2 ❑ 30 ARREST NAME Figueroa. Linda. K. 11-601 1550-00133 ! ! 0 pM ElUnknown work zone type U1 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ElAM Workers present? ❑Y 30 1550-Camiacho.Oscar 301 331-Ziegler 09 !09 l2025 01 30 El 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 -< ` --I -' A - INDICATE NORTH combination):or -I I I.i BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C N _ } (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 - i. } } } transporting employees In the course of their employment(example:employee X transporter-usually a van type vehicle or passenger car):or w L L.___a____� 4. Is used ordesi natedtotrans rtbetween9and15passengers,includingthedriver. C ■ _ ' l` I. } } for direct compensation(example:large van used for speific purose):or 0 I I I t_ w'; we - } } } 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires /1 � •D placarding(example:placards will be displayed on the vehicle). XI AM.�,a _ D CARRIER NAME Z Z ADDRESS 0 C) Not To Scale CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate ❑ Intrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other ‘I. - --1 - % % % % USDOT NO. ILCC NO. m XI Source of above z own tank)? 0 Yes 0 No 0 Unknown Did HAZMAT Regulations violation contribute to the crash? r ❑ Yes 0 No 0 Unknown g D Did Carrier Safety Regulations MCS)violation contribute to the crash? A ❑ Yes II El Unknown C 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' -n TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 o u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Maroon Black u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. Arties/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 2 TOWED BY/TO: DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE