HomeMy WebLinkAbout2025-00061468 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 El$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY El OVER$1,500
El NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00061468 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 m® ❑ RELATED 0 Y ®N 09 18 2025 ❑AM ❑YES ®NO U1 —<
N STATE ST Elgin PRIVATE mo /day/yr 1126 ®PM FLOW CONDITION m
®20�F !MI N E O W Kimball St COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
Kane HIT&RUN ❑V ® N WITH VEHICLESOT,
INVLD DO
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❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
(i DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑uuv ❑ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
FOR DAMAGEDAREA(S) FRO T TOWED U1 Q
Juarez Morales.Vicente 0 7 /
yr 13-UNDER CARRIAGE IE
fa !!. 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
M 9 SY9 ❑Y ❑SNE®UNK VEH. 9 AT CRASH M IN 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 7 i� a ..4 COM VEH 0 Ea 1 n
~ ELGIN IL 60120 0 9 0 FIRST CONTACT 5 7 : _O =IIYes.SeeSidebar U1 0
Z 3397052B IL 2018 REAR
TELEPHONE
IL D 0 1 FTEW1 EG7JFC27314 StateFarm ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 1758046-sfp-13 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 99
x DRIVER ❑ PARKED ❑DRIVERLESS 0 FED ❑PEDAL 0 EWES ❑New 0 KDV ❑DV
0 0 5 Nissan Pathfinder 2017 00-NONE O,' t2 "_, DUE TO CRASH ❑ 2 x
0 13-UNDER CARRIAGE 10 I 2 FIRE 0 ® U2 C
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M 2 4 SYSTEM IN 9 ENGAGED 9 15-OTHER 9,16-TOP 3 X
❑Y ❑N ®UNK VEH. AT CRASH 99-UNKNOWN •Oistracton Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 5
FIRST CONTACT 11i1 1I 4 COM VEH 0 ® U1 W
8 7 _5 •(ryes,See Sidebar
— Hampshire IL 60140 0 1 0 BB73849 IL 2025 REAR 0 Si)
IL D 0 5N1DR2MN9HC683265 State Farm ®Y ❑N RDEF 7J
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Nava,Alexis G592537C0113 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 91 )81 ,025 11 26 ®PM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
57 2 0 04 99
N 3 ❑ ❑CITATIONS ISSUED 0 PENDING + ) ❑PM• El Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5
—a, ARREST NAME / / El PM '
o N ® 11 1 •
0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility SLMT
t 2 ARREST NAME AM
7 , , ❑❑PM 0 Unknown work zone type U1
El
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 1522-Velazquez. Noeli 601 331-Ziegler , / ❑❑PM Workers present? ®N U2 30
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 -' I. INDICATE NORTH combination):or —I
A
i BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
I ` ` rorowa - (example:shuttle or charter bus):or 0
1 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
} I• . transporting employees in the course of their employment(example:employee X
r transporter-usually a van type vehicle or passenger car):or w
L L.___a____. 4. Is used ordesinatedtotrans rtbetween9and15passengers,includingthedriver. C
I I t } } for direct compensation(example:large van used for speific purose):or
L L--_-a-___. I ey/ - t i iany 5. Is any vehicle used to transport hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle).
, CARRIER NAME Z
ADDRESS 0I (
n
NotI CITY/STATE/ZIPg
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
--- --4. - USDOT NO. ILCC NO. m
XI
Source of above z
. Form Number m
Xl
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
a
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 ® NOT DISABLING DAMAGE DAMAGE EXTENT: 0 TOWED BY/TO:
_ . 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