HomeMy WebLinkAbout2025-00058892 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003950063
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 202512025-00058892 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 mDUNDEE AVE El 05:34
® ❑ RELATED ®Y 0 N 09 07 2025 ❑AM YES ®NO U1
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION Ill
FT!MI N E S W COOPER AVE COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR El SLOW 15 to
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
0 4 /
yr 13-UNDER CARRIAGE 101 !�. 2 FIRE 0
NI
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
M I 2 4 SYTM❑Y ®SNE EDUNK VEH. 0 AT CRASH 99-UNKNOWN THER9 16•TOP 3 ,Distraction Value ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ iI a �i 4 COM VEH 0 El 1 0
~ ELGIN N I L 60120 0 1 0 FIRST CONTACT 1 7 ;- -_5 *If Yea.See Sidebar Ut
ZDZ47340 IL 2026
TELEPHONE
IL D 0 1 GYS4BKJ5KR404435 State Farm ❑Y Il N U2 13 . m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 1757058-SFP-13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 2 0
m g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEOAL 0 EWES ❑lily 0 i v ❑Dv
yr/1 9 9 5 Mazda CX9 2023 00-NONE 1("j 12..-_1 DUE TO CRASH 0 ❑ 2 x
.. 13-UNDER CARRIAGE 10'1 c., 2 FIRE 0 El U2 C
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOPO3 * X
❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN i O OistraMon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s- 1. 0 jl 4 COM VEH ❑ ® U1 CO
FIRST CONTACT 3 7�'—_,SOS •If Yes.See Sidebar
E LG I N I L 60123 0 1 0 D R77947 I L 2025REAR C
IL D 0 JM3TCBDYOP0636032 Progressive ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 861703273 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (0081 (SEX) {SAFT) (AIR) (WI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
2 3 05 /
U1 1 D
/ / 2 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 4 09/07 /2025 05 34 ®AM 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 2 28 09,07 /2025 05 42 ®PM ❑Construction
1
R 3 ❑ ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
J ❑AM ❑Maintenance U2
- NSECTION CITATION NO. ROAD CLEARANCE TIME
a, ARREST NAME LORENZO.WILFRIDO 11-901 1560000081 09/07/2025 05 45 ®PM SLMT
1 ® 11 4 0 CITATIONS ISSUED PENDING Utilit
oA 0 y
r 2 El ARREST NAME 09/07 /2025 05 40 0 PM ❑Unknown work zone type U1 30
2 2 3 ID
ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1560-Jones. Bennett 201 10 ,07/2025 09 00 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.
I undee?Ave.
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 truckrtrailer -<
i- ----_r_-__; I combination)or
INDICATE NORTH p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
C
} (example:shuttle or charter bus):or
I Cooper?Ave 3. Is desgned to carry15 or fewer passengers and operated a contract carrier O
} } } transporting employee in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or CO
L 4. Is used or designated to transport between 9 and 15 passengers,including C}--- ----; ,� - } } } g po passen rs,includi the driver,
for direct compensation(example:large van used for specific purpose):or O
L t ii. L5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
_a -� placarding(example:placards will be displayed on the vehicle). XI
J' 7 i CARRIER NAME Z
1 ADDRESS0
NT.
Not To Scale _i CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate 0 Intrastate
❑ Not in Comm./Govt. ❑ Not in Comm./Other
O
--- --1 I - USDOT NO. ILCC NO. C
m
XI
Source of above z
. If Yes,Name on placard 0
4 digit UN NO. 1 digit Hazard class No. XI
XI
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z
own tank)? 0 Yes 0 No 0 Unknown
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes ❑ 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
to
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
Black 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 Other/Unknown VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE