HomeMy WebLinkAbout2025-00059989 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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INVESTIGATING AGENCY DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S 0$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
El AMENDED
YR 202512025-00059989 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED ®Y 0 N 09 12 2025 ®AM ❑YES ®NO U1
BODE RD Elgin07:58
_ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FT!MI N E S W LINDEN AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ Cook HIT&RUN ❑Y ® N WITH VEHICLES INVLD DO
U2 --I
Igl AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 NIAV 0!CV ❑ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
f4T TOWED U1 Q
Mendoza.Yohan.Y. Acura TL 2008 00-NONE 11_• ! 0 2 12 DUE TO CRASH ® ❑
NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 101 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 2 m
M 2 4 ❑Y ®SNE❑UNK VEH. ATCRASHIN n ENGAGED 99-UNKNOWN 9 76•TOP 3 •Distraction Value 9 ALGN =
•
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ iI 6 �i,4 COM VEH ❑ j$J 2 O
~ ELGIN IL 60120 0 1 0 FIRST CONTACT 1 7 ; __5 *IIYes.See Sidebar U1
ZFE58901 IL 2026 REAR
TELEPHONE
IL D 19UUA765X8A037140 State Farm ❑Y J N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
Mendoza. Elvia 3570907SFP13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 73
m x DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑i,uv 0 i v 0 DV
!1 9 yf 4 Honda CRV 2016 00-NONE 1t 12 (_2 FIRE DUE O CRASH 0 ® U2 2 C73
o 13-UNDER CARRIAGE
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F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN •Distrac)i n Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 0'ii- 6 j1:_4 COM VEH ❑ ® u1 CO
C
FIRST CONTACT 8 7 -5 •If Yes.See Sidebar
H ELGIN IL 60120 0 1 0 BY55213 IL 2026 I 0 Si)
IL D 3CZRU6H79GM769694 Country Financial ❑Y ®N RDEF M
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Same PO10420785 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused 0 Y°ND
0 N U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
E/ MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 CD 11 4 co
09,12 l2025 07 58 ®❑PM in a Work Zone? NJ DIRP D
1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 5 n
Si T
2 ❑ 23 2 , , 0 PM 0 Construction *
Z 3 ❑ 1!>I CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM 0 Maintenance U2
o1 ® 11 4 ARREST NAME Mendoza.Yohan.Y. 11-1204-B 1504000530 / ! El PM SLMT
o N 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility
25
T 2ARRESTNAME AM
T ❑PM 0 Unknown work zone type U1
El 1 r ❑
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 25
1504-Real, Hilario 302 10 ,28,2025 01 30 ®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 -<
i- }__-_r_-__1 CD BY
NORTH combination):or —I
-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
1 (example:shuttle or charter bus):or
1 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
A
} } } transporting employees In the course of their employment(example:employee X
I transporter-usually a van type vehicle or passenger car):or CO
L -----------; 1 - • } } } 4. Is used or designated to transport between 9 and 15 passengers,including the driver, N
S \ for direct compensation(example:large van used for specific purpose):or O
L L____a____.: \ r i i L 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m
1
r r placarding(example:placards will be displayed on the vehicle). XI
�� D
1 - _- CARRIER NAME Z
4 r
°p6f ADDRESS 0f r l D
CITY/STATE/ZIP 0
- a1p`r°1 - i. i. 4. MOTOR CARR.ID ❑ Interstate ❑ Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
; _Y_ __1 - USDOT NO. ILCC NO. m
XI
Source of above z
. If Yes,Name on placard 0
4 digit UN NO. 1 digit Hazard class No. Xl
Xl
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 0 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
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
Silver White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Redmons/Owners Residence . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE