HomeMy WebLinkAbout2025-00055068 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 6 Sheets II 1 III 11 II I1 II IIIIII 01100101111111lI111
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑5501-51.500 ®ON SCENE 3
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
El AMENDED
YR 202512025-00055068 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 FI
965 DUNDEE AVE El In04:15
® ❑ RELATED ❑Y ®N 08 23 2025 ®AM ❑YES ®NO U1 -<
_ g PRIVATE mo /day/yr ❑PM FLOW CONDITION M_
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR IR SLOW fA
❑ FT/MI NESW Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD ❑ STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 uuv 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0
1 0 /
yr 13-UNDER CARRIAGE 101 !!. 2 FIRE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 0-TOTAL(ALL) DISTRACTED 0 0 U2 III
M 9 SY9 ❑Y ❑STM NE CD UNK VEH. 9 AT CRASH 9 99-UNK 15- NOWN THER9 t6•TOP 3 ,Distraction Value 9 ALGN
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r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s 6 I,.4 COM VEH 0 El tit O
V. 1 Rolling Meadows IL 60008 0 9 9 FB63772 IL FIRST CONTACT 12 Y , _s ves.See Sidebar
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TELEPHONE
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13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
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99 9 Same NIA 1 I-
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER
yr 12 _ X1
o 13-UNDER CARRIAGE 10 1 c. 2 FIRE 0 ❑ U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 0 0 SPDR 0
0 Y ❑N 0 UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value U1 3 -
POINT OF s-.;, 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRSTO CONTACT Y 6 I,_
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M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O
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EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
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HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
RESP❑YD❑N NDER U1 =
(UNIT) (SEAT) (008i (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME(((A.DDRESS)/(TELEPHONE) (EMS) (HOSPITAL) 0
1 4 1 0 /
LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 0 43 3 City of Elgin.City of Elgin Traffic signal 08,25 ,2025 04 15 ®❑PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1
2 ❑ 29 3 150 DEXTER CT ELGIN IL 60120 06 28 08,23 ,2025 04 16 PAA
1 ❑ 0 Construction >F
N 3 ® 3 3 El CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME
z J ®AM ❑Maintenance U2
- El Utility
a, ARREST NAME BARRERA.XAVIER.J. 11-601 752917 08,23 r2025 04 25 ❑PM
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U ig!CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME
N ❑AM U130
t 2 El ARREST NAME BARRERA.XAVIER.J. 11-401-A N/A , r ❑pM ElUnknown work zone type
n OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y
2 3 0
1550-Camiacho.Oscar 201 331-Ziegler 09 ,25,2025 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
«nwiees,wn. 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
r r -' -' r INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} - i. e. r r (example:shuttle or charter bus):or 0
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,xrvi 3. Is desgned to carry15 or fewer passengers and operated a contract carrier O
- N - } } } transporting employee In the course of their employment(example:employee X
-- -- I I transporter-usually a van type vehicle or passenger car):or w
L4'—— 4. Is used or designated to transport between 9 and 15 passengers,including C
} for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or o
.D
l. i i 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
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�,,,! — placarding(example:placards will be displayed on the vehicle). D raodae
CARRIER NAME Z
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ADDRESS 'n
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I I CITY/STATE/ZIP 0
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Not To Scale I MOTOR CARR.ID 0 Interstate ❑ Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
;------ --1 - USDOT NO. ILCC NO. m
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
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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_COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Red
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Adieu/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U_TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/T6
DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE