HomeMy WebLinkAbout2025-00058946 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 I011011001 I0
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003958393
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 202512025-00058946 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r7
SUMMIT ST Elgin® ❑ RELATED ®Y 0 N 09 07 2025 12,— ®YES El NO U1
10:33
_ _ g PRIVATE mo !day!yr ®PM FLOW CONDITION m
FT N E S W BERNER DR COUNTY PROPERTY El ® N DOORING ❑y #OF MOTOR El SLOW 1 cn
❑ Cook HIT&RUN ®Y ❑ N WITH VEHICLES INVLD ❑ STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ® FREE FLOW # LNS 0
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 0 C)
1 0 /
yr 2010
Ovalle. Brian Mitsubishi Lancer 00-NONE •0 >2 >,/OUETOCRASH ® ❑
13-UNDER CARRIAGE I • FIRE ❑ tz
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED ❑ ]Si U2 0 m
M 2 6 ❑Y ESYlM®UNK VEH. 9 AT CRASH D 9 99-UNKNOWN 9 16•TOP�3 *Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s.;il S �I COM VEH ❑ El 1 0
I . 60110 0 1 0 FIRST CONTACT 3 7 .— -_5 *uYes.See&debar Ut
Z DD22634 IL 2025 Isui
TELEPHONE
IL D JA32U2FUXA0007596 State Farm ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
OVALLE ZAPATA.JOSE.G. 3464696-SEP-13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 XI
x DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 Nero 0 NOV 0 DV
!1 9 yr 2 Hyundai Sonata 2011 00-NONE O, ' ni O DUE TO CRASH rg ❑ 2 x
... 13-UNDER CARRIAGE FIRE 0 ® U2 C
il
F 2 5 SYSTEM IN 9 ENGAGED 9 15-OTHER 9 16-TOP 3 X
❑Y ❑N ®UNK VEH. AT CRASH 99-UNKNOWN *0istraellon Value 9
POINT OF S i1 0 4 COM VEH ❑ ® U1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 12 7� J-5 *If Yes.See Sidebar
— Des Plaines IL 60018 B 1 0 E824427 IL 2026 aR 9 n
IL D 5NPEC4AB5BH296286 Kemper ❑Y ®N RDEF ZI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 X
Elgin Fire Same 12A0001167200 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Provena St.Joseph RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((A.DDRESS)(TELEPHONE) (EMS) (HOSPITAL)
2 3 1 2 /
:A
/ / UI 1 D
/ / 2 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 4 09,07 /2025 10 33 ®FM 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 0 06 2 09,07 ,2025 10 33 PM
® • ❑Construction >E
Z 3 0 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM ❑Maintenance U2
ARREST NAME 09,07/2025 10 37 ®PM
au 1 ® 1 1 1 ❑CITATIONS ISSUED ❑PENDINGSLMT
o N SECTION CITATION NO. ROAD CLEARANCE TIME
AM• 0 utility
t 2 ® 11 1 ARREST NAME 09/08 12025 00 47n PM ❑Unknown work zone type U1 50
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ID AM Workers present? ❑Y 50
1517-Le Cates. Brittany 202 223-Hughes / / ❑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 truckrtrailer -<
` ` --I -' r INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i I (example:shuttle or charter bus):or
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A I �i 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 73
pBanw900Elpin transporter-usually a van type vehicle or passenger car):or CC
D__ f _ 4. Is used or desi nated to trans rt between 9 and 15} } } g po passengers,including the driver, to
1 for direct compensation(example:large van used for specific purpose):or
__ __ -"P�4�1"r ""2 t_ l I 1 L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
�u�rra_ ��9 � >�� _ placarding(example:placards will be displayed on the vehicle). XI
- CARRIER NAME Z
aanrruua,arxn 1 I r rO
Not To Sosle ADDRESS
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I CITY/STATE/ZIP 0
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MOTOR CARR.ID 0 Interstate 0 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
. IDOT PERMIT NO. WIDELOAD'; 0 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
Red Gray
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ElNOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO.
Redmons/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE