HomeMy WebLinkAbout2025-00061649 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003969732
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INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and f or Tow Due To Crash YR 202512025-00061649 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 mWAVERLY DR Elgin
® ❑ RELATED ®Y 0 N 09 19 2025 ❑AM ❑YES ®NO U1 -<
PRIVATE mo /day/yr 04:40 ®PM FLOW CONDITION ITT
010 ®!MI O E S W Summit St COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR El SLOW 1 (n
Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD ® STOPPED U2 --I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ❑ FREE FLOW # LNS 0
183 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0(CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FOR DAMAGEDAREA(S) FRONT TOWED U1 Q
NAME(LAST,FIRST,M) mo
/1 9 6 5 Nissan Rogue 2021 00-NONE „ i•, DUE TOCRASH ❑ EN
13-UNDER CARRIAGE ) 2 ' 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL)THERDISTRACTED 0 0 U2 2
10 rr1
M 2 SYTM 4 ❑Y ®S NE DUNK VEH. O AT CRASH 0 15-99-UNKNOWN 9 76•TOP 3 *Distraction Value 9 ALGN 2
T CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $,_iL 6 I,.4 COM VEH 0 j$J 1 O
~ ELGIN I L 60120 0 1 0 FIRST CONTACT 12 7 ; _5 *If Yes.See Sidebar IA
Z CF91511 IL 2026
TELEPHONE
IL D 0 J N 1 BJ 1 CW7MW423370 State Farm ❑Y ®N U2 I'
IL'in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Cruz.Yolanda 3018704SFP13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER
2 XI
x DRIVER 0 PARKED 0 DRIVERLESS ❑ FED 0 PEDAL 0 EWES 0 row 0 NOV 0 DV
/1 9 9 7 Kia Motors Colptinger 2022 00-NONE ,�_"i 12'"_, DUE TO CRASH ❑ 2
0 13-UNDER CARRIAGE 10 l z FIRE ❑ ® U2 C
c
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP 3 X
❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *OistractIon Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 I 6 .!.,_4 COM VEH ❑ ® ut W
H FIRST CONTACT 6 7A-�-'_5 •If Yes.See Sidebar C
ELGIN IL 60120 0 1 0 Q577686 IL 2026 i0 Si)
M
IL D 0 KNAE55LC3N6099666 American Family ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 101067660362FPPAIL BAc E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER
U1 =
(UNIT) (SEAT) (DOB' (SEX) {SAFT) (AIR) (INJ) 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
2 6 09 /
' D
/ / 4 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 1 9/ /9/ /025 04 40 ®AM 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
o"
2 ❑ 28 99 / / 0 PM• 0 Construction *
R 3 ❑ $I CITATIONS ISSUED 5 PENDING SECTION CITATION NO. EMS ARRIVED TIME
❑AM 0 Maintenance U2
o 1 ® 11 1 ARREST NAME Mejia. Michael.V. 11-601-Ax S1924-000463 / / El PM SLMT
I$!CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility
8 N ❑AM 30
t 2 El ARREST NAME Mejia. Michael.V. 6-303-A S1924-000461 ! / ❑pM 0 Unknown work zone type U1
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ ❑AM Workers present? ❑Y 30
1524 Silva Jose 202 269-Mendiola ! / ❑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••--, , I ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
�___--I--___; I _ 1. Hasa or weight
truck or truck trailer -<rating more than 10,000 pounds(example:
INDICATE NORTH p0
Unh41 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
VilavertY7Dr. I } ,. ,. ,. (example:shuttle or charter bus):or 0
I- <-----I----; Unit/2 ii transporting mployeened to slin the course passengers5 or fewer thir emplod yment example:employee
transporter} } }
' 6ransportet-usually a van type vehicle or passenger car):or co
C
L i.-----}----; - - } I- } 4. Is used or designated to transport between 9 and 15 passengers,including the driver. N
ll for direct compensation(example:large van used for specific purpose):or 0
L L____a____. — _ t i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
D
gu placarding(example:placards will be displayed on the vehicle). m
0
1 -- 2:.I CARRIER NAME Z
ADDRESS 0
T.
0 I CITY/STATE/ZIP
MOTOR CARR.ID El Interstate El Intrastate .5I r I ❑ Not in Comm./Govt. 0 Not in Comm./Other 00
;---_Y____.; I Not To Scale I - USDOT NO. ILCC NO. C
m
XI
Source of above Z
. 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'; 0 Yes 0 No 2
TRAILER VIN 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Maroon White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT 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: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE