HomeMy WebLinkAbout2025-00058452 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ®5501-$1.500 ❑ON SCENE 1
VEHICLE/PROPERTY ❑OVER$1,500 ®NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00058452 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 f1
SPARTAN DR El In00:20
® ❑ RELATED ❑Y ®N 09 05 2025 ®AM ❑YES IX]NO U1 -<
_ _ g PRIVATE mo !day/yr ❑PM FLOW CONDITION m
FT N E S W S MCLEAN BLVD COUNTY PROPERTY ElY ® N DOORING ❑Y #OFMOTOR El SLOW 15 Co
❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD ® STOPPED U2 —I
lgi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 C)
FOR DAMAGEDAREA(S) FRONT TOWED U1 0
NAME(LAST,FIRST,M) Unknown.O. mo ! / yr Unknown Unknown 00-NONE „ R'OO i-, DUE TO CRASH ❑
EN
13-UNDER CARRIAGE 10 : 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0U2 3 <<T1
SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3
F 9 9 ❑Y ❑N ❑UNK VEH. AT CRASH ®-UNKNOWN `Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S_iL 6 �i, COM VEH ❑ j$J 1 0
~ 0 9 0 FIRST CONTACT 12 7_; _5 *IIYes.See Sidebar Ut
REAR
2 Z ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 lii
NIA ❑Y ❑N U2 At , m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same NIA 1 I-
`o HOSPITAL(TAKEN TO) INCIDENT IF'V OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Refused ❑Y ❑ N 99 0
m g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES 0 114V 0 KCv 0 DV
!1 9 yr 4 Mazda CX5 2022 100 3-NONE 'o,1 t2 c,�2 FIRE DUE O CRASH 0 ® U2 2 cXj
o - 13-UNDER CARRIAGE
c
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distract Dn Value 9 g
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-.;, 6 I!I,-4 F.OM VEH D ® U1 CO
F,,, FIRST CONTACT 5 7 _,SOS •(ryes,See SidebarC
ELGIN Z IL 60123 0 1 0 V358843 IL 2026 REAR g
Sn
M
IL D JM3KFBEM1 N0548330 Allstate ❑Y J N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 811612979 BAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND 0 N u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
u 1 ® 11 1 09,05 l2025 03 55 ®AM 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 C)
2 ❑ 15 18
N 3 ❑ 0 CITATIONS ISSUED 0 PENDING + ! 0 PM• ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
-a, ARREST NAME ! / ID PM '
o N ® 11 1 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
SLMT
35
ARRESTNAMEAM
7r 2 ❑ ❑❑PM 0 Unknown work zone type U1
/ ,
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 560-Martirez.Samantha 701 269-Mendiola , / ❑❑PM Am Workers present? ®N U2 35
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 -' r INDICATE NORTH combination):or .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i_ - } (example:shuttle or charter bus):or 0
N y ;
3. Is designed to carry15 or fewer passengers and operated a contract carrier 0
< I- -- 1
1 } } } transporting employee �In the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or w
C
L L.___a__._. s - 4. Is used ordesi natedtotrans rtbetween9and15passengers,includingthedriver,
CM } } } . for direct compensation(example:large van used for speific purose):or 0
L L----a-- "—r"eY— - t l I. 1 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). ;p
I4.0Fftalf404I - , ,• ,• , , CARRIER NAME Z
ADDRESS 0Mot To Scale j D
CITY/STATE/ZIP 0
MOTOR CARR.ID 0 Interstate 0 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 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Blue
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 9 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE