HomeMy WebLinkAbout2025-00056331 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 011011001 0
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003945762
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INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 3
VEHICLE/PROPERTY [8]OVER 31,500 El NOT ON SCENE(DESK REPORT) El B Injury and/or Tow Due To Crash
El AMENDED
YR 202512025-00056331 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1
® ❑ RELATED ❑Y ®N 08 28 2025 ®AM ❑YES ®NO U1 -<
RT20 EB Elgin06:06
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION ITl
FT!MI N E S W S STATE ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 1 (n
❑ Kane HIT&RUN ❑V ® 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 ❑ PED ❑PEDAL ❑EOUES ❑NW ❑ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0
0 7 /
Toyota Camry 2007 00-NONE 11 Oi_, ouETOCRASH El 13-UNDER CARRIAGE 1a i , 2 FIRE 0
NI E
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 4 rn
M 2 SYTM 4 ❑Y ®SNE DUNK VEH. 0 AT CRASH 15-99-UUNKNOWN THER9 76•TOP 3 *Distraction Value ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s_iL B I,.4 COM VEH 0 Ea 1 0
~ ELGIN IL 60123 0 1 0 FIRST CONTACT 12 7_; _5 *IIYes.See Sidebar U1
Z BW38522 I L 2026 REAR
TELEPHONE
IL D 4T1 BE46K870003754 Kemper ❑Y igi N U2 13 , m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire Same 12AU001008944 2 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 X
m g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑iiuv 0 i v ❑Dv
!1 9 9 6 FROM TOWED
Camry 2017 00-NONE 11_"j Q1:-_, DUETO CRASH rg ❑ 2 x
oYr 13-UNDER CARRIAGE 1U/ I.. 2 FIRE ❑ ® U2 C
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X
❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value 3
POINT OF 8 iI 4 COM VEH D ® Ut W N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR - all,,
FIRST CONTACT 6 Y__{_O ._5 •IfYes.SeeSidebar
— Wheaton IL 60189 0 1 0 NZW7353 TX 2026 i 0 C
TX A 4T1 BF1 FK9HU748204 Root Insurance ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire Same QJT2LC SAC E
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 3 05 / F 2 3 0 1 0
m
/ / #OCCS D
/ / UI 2 D
/ / 1 0
E/ MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 El 11 1 08/28 /2025 06 06 ®❑PM in a Work Zone? ®N DIRP 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 C)
v 2 28 03 08,28 /2025 O6 O6 ❑PM El Construction
4
R 0 0 CITATIONS ISSUED El PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
3 ®AM 0 Maintenance U2
o1 ® 11 1 ARREST NAME Palencia-Pena. Denis, M. 11-601 298001292 08/28/2025 06 12 ❑PM SLMT
o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility
AM 55
r 2 0 11 1 ARREST NAME 08/28 /2025 06 47 M PM ElUnknown work zone type u,
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 55
298-Lopez, Mirko 700 10 , 14/2025 01 30 0 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 -<
c ` --I -' r INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- } (example:shuttle or charter bus):or
N
3. Is designed to carry15 or fewer passengers and operated a contract carrier O
�_ A 1- ___ ___-
- }} } transporting employee � �In the course of their employment(example: �employee X
Not n Sabre ' transporter-usually a van type vehicle or passenger car):or co�, C
I- I- --I-----; a�'o"% - } } 1. 4. Is used or designated to transport between 9 and 15 passengers,including the driver, y
•for direct compensation(example:large van used for specific purpose):or
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71
L l. i i .. 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). ;p
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CARRIER NAME Z
ADDRESS 0
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CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate El Intrastate
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
‘I. - --1 - USDOT NO. ILCC NO. m
XI
Source of above z
'
. 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'I COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Silver Gray
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 2 TOWED BY/TO.
SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE