HomeMy WebLinkAbout2025-00060036 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
I01101100101111110100
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X0039666 5
u, 1 U21 1 1 1 U1 9 U2 1 U1 1 U2 1 U, 1 U2 1 1 15 U,23 U2 1 *P 0119
INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 7
VEHICLE/PROPERTY El OVER$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00060036 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 m66 GROVE CT El In11:44
® ❑ RELATED 0 Y ®N 09 12 2025 ®AM ❑YES El NO U+ -<
g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
_
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 2 fA
❑ FT!MI N E S W Kane HIT ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
&RUN
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
0 1 FOR DAMAGEDAREA(S) FRONT TOWED U1 0
2016
NAME(LAST,FIRST,M) Lara Martinez.Omar mo
Ford Transit Connect 00-NONE + OUE TO CRASH ❑ EN
! ! yr ++- +2
13-UNDER CARRIAGE 161 2 FIRE 0IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 0 m
M 2 SY 15-OTHER
4 ❑Y ®SNE DUNK VEH. 0 AT CRASH M IN D 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ iII 6 ii,4 COM VEH 0 j$J 1 00
~ ELGIN I N I L 60124 0 1 0 FIRST CONTACT 6 7:_:LQ--5 *Ir Yes.See Sidebar U1
Z 1936699B IL 2025
TELEPHONE
IL D NMOLS7E72G1246376 AAA ❑y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same AUT700919790 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y ❑ N 2 0
tg DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 iiuv 0 i v 0 DV
yr 12
0 13-UNDER CARRIAGE 19( 2 FIRE ❑ ® U2 C
c
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-it 6 1l, COM VEH ❑ ® U1 CO
FIRST CONTACT 1 Y _, _5 •(ryes,See Sidebar
H E LG I N I L 60123 0 1 0 3293110 B I L 2026 REAR
C
M
IL D 1 D7RV1 CT5BS651240 The General ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 1 B-I L 8543546 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND O N U1 =
(UNIT) (SEAT) (DOBI (SEX) {SAFT) (AIR) (INJ) (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 0 Y U2 Z
N 1 ® 11 1 09,12 /2025 11 44 ®❑pm 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
2 0 14 28
N + 3 ❑ ❑CITATIONS ISSUED ID PENDING + ❑PM 0 Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 7
-a, ARREST NAME ! ! El PM '
o u ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT
05
t 2 ARREST NAME AM
7 1 r ❑❑PM 0 Unknown work zone type U+
El
n OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 - ❑AM Workers present? ❑Y 05
426 Joniak. Matthew �07 , , ❑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.
A CMV is defined asmotor vehicle used to transportand:
r ----,5-••--, ; any passengers or property
Z
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
} i.-- -i-- --; } } } r -, , ; ; , 1, ( INDICATE NORTH combination):or —I
p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ' , } (example:shuttle or charter bus):or
X
3. Is
. L.___A_. 1 i. ..._- - J transporting edmployeeslin5 hecourseeo theire rsmployment exam pal
e:employeener 73} } }
transporter-usually a van type vehicle or passenger car):or c0
I- <.__-a-_-_-I , l• I- I- <--_-a-___� , , , , 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or 0
L L___-a____.: L L L ...._-..i.____� t i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires III
placarding(example:placards will be displayed on the vehicle). XI
--I
CARRIER NAME Z
i.
ADDRESS 0
T.
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other O
USDOT NO. ILCC NO. m
XI
Source of above z
. —I
Were HAZMAT placards on vehicle? 0 Yes 0 No =
If Yes,Name on placard O
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
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
White Red
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ElNOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE