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HomeMy WebLinkAbout2025-00057229 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I011011001 flhlll III fl 1100 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003943086 u, 1 U21 1 1 1 u, 4 U2 1 u, 1 1_12 1 1.11 1 U2 1 1 11 u1 1 U211 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 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 15 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash 0 AMENDED YR 2025I 2025-00057229 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 —n ® ❑ RELATED ®Y 0 N 08 31 2025 ❑AM ❑YES ®NO U1 S MCLEAN BLVD Elgin06:48 _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m FT!MI N E S W SH U LER ST 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 51 FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEOAL 0 EOUES 0 uuv 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 00 n 0 1 , yr 13-UNDER CARRIAGE ©, :: FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0U2 OO M M 2 SY5 ❑Y ONM DUNK VEH. O AT CRASH IN O 15-OTHER 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S, i�S 4 COM VEH 0 0 1 O ELGIN I N I L 601 20 0 1 0 FIRST CONTACT 12 7 ; __5 *it ves.See Sidebar U1 Z FF31242 IL 2026 E TELEPHONE IL D JM3ER2W51A0332368 First Chicago ❑v Il N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Velasquez. Maria.A. ILS1131440-00 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 73 p; DRIVER 0 PARKED 0 DRIVERLESS ❑ PED 0 PEDAL 0 EWES 0 l uv 0 i v 0 Dv 1 9 9 2 Honda Civic 2024 00-NONE 'o_I 12 z FIREO CRASH 0 ® U2 2 C o mo 13-UNDER CARRIAGE c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16•TOP 3 ❑Y NJ N DUNK VEH. AT CRASH 99-UNKNOWN *0istraglon Value 9 g N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S 1 S .i. 4 COM VEH ❑ ® Ut W F,,, FIRST CONTACT 6 O7 ,�=Q)OS •It Yes,See Sidebar C ELGIN IL 60123 0 1 0 CH30679 IL 2026 aR 0 fp M IL D 2HGFC2F62LH599834 State Farm ❑Y ®N RDEF 7) EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Same 2988792-SFP-13 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER u1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 1 0 E/ MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 11 4 $) , 11 ,025 06 48 ®PM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 � o" 2 0 28 99 , , 0 PM• ElConstruction >F Z3 0 I!!I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5 o1 ® 11 4 ARREST NAME Melo Velasquez.Johan. E. 11-601 1506-442 , r El PM SLMT o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • [3 Utility t 2 El35 AM NAMEAM 7 ❑❑PM ❑Unknown work zone type U 1 / 1 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 35 1506-Nunez. Maria 602 269-Mendiola 10 , 14,2025 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••--, , III+ . A CMV is defined as any motor vehicle used to transport passengers or property and: Z UNIT 1 N 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< .. }-----I-----' _ II - } INDICATE NORTH combination):or -I Not To Scale BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver n _ } (example:shuttle or charter bus):or P.O.I. . . . . T, 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 transporter-usually a van type vehicle or passenger car):or w L L.___a__ g I. 1 4. Is used ordesi natedtotrans transport passengers,including y} } } g po specific p rs,):or i the driver, UNIT 2 for direct compensation(example:large van used for cific purpose):or _ t . i. _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example:placards will be displayed on the vehicle). m &i XI CARRIER NAME Z SHULE(YlST - ADDRESS 0 o n CITY/STATE/ZIP g -1 r . . . . MOTOR CARR.ID 0 Interstate 0 Intrastate I I T I ❑ Not in Comm./Govt. Not in Comm./Other ;_...Y. ._ 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 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 ❑ o u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. 0 Purple Black u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. _Mies/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