HomeMy WebLinkAbout2025-00064716 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 1011011001 OIl
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 2025512025-00064716 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
RAYMOND ST Elgin 07:06
® ❑ RELATED ®Y 0 N 10 02 2025 12,— ❑YES ®NO U1 -<
_ _ g PRIVATE mo !day!yr ®PM FLOW CONDITION m
FT!MI N E S W NATIONAL ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR IR SLOW 1 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
0 3 /
yr 13-UNDER CARRIAGE 10.I 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14--TOTAL(ALL) DISTRACTED 0 0 U2 2 m
M 2 OTHER
4 ❑Y ®SYSNEM IN❑UNK VEH. O AT CRASH D O 99-UNKNOWN 9 76.70P 3 ,Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s it S 4 COM VEH 0 j$J 1 0
~ ELGIN IL 60123 0 1 0 FIRST CONTACT 12 7_;1 __5 *IIYes.See Sidebar U1
Z FG52470 IL 2025 REAR
TELEPHONE
IL D 0 2G2WP552771172106 NONE El ® 4 U2 I—
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in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same NONE 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y ® N 2 0
g DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED 0 PEDAL ❑EWES O Nuv 0 NOV ❑DV
!2 O O O Infiniti G20 2012 00-NONE 'o,1 t2 c,�2 FIRE DUE ID
CRASH 0 ® U2 1 C o mo 13-UNDER CARRIAGE
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SYSTEM IN 0 ENGAGED 0 ®-OTHER 911,6•TOP3 9 0 X
i NDUNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 1 S .t. 4 COM VEH ❑ ® Ut CO
F,,, FIRST CONTACT 6 O7 ,�=Q)OS C.
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ELGIN Z IL 60120 0 1 0 FM21597 IL 2025 FIRST
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OTH Other 0 J N 1 DV6AR2CM860310 Kemper ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 12ra000072465 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
U1 1 D
/ / 1 0
E/ MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 10,02 l2025 07 06 ®PM 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
O 2 0
28 03 ! ! ❑PNI ❑Construction *
Z 3 0 xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM 0 Maintenance U2
o ® 11 1 ARREST NAME Nieto-Morales.Alfredo 11-601 747911 / ! El PM SLMT
ljg CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' 0 Utility
o N AM20
T 2 ElARREST NAME Nieto-Morales.Alfredo 11-402-A 747910 , r DI PM ❑Unknown work zone type U1
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 20
485-Quintana.Josue tot 10 ,30,2025 09 00 ❑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
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1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
} 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
} ' i 1 , } (example:shuttle or charter bus):or
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3. Is
L L.___A_. . ..._- - . transporting edmployeeslin5 hecourseeo theire rsmployment example:employeener
} } }
transporter-usually a van type vehicle or passenger car):or co
< <.__-a-_-_, , l• < <--_-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 ...._-..:_____� t i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). XI
--I
CARRIER NAME Z
ADDRESS 0
T.
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other 0
USDOT NO. ILCC NO. m
XI
Source of above z
. m
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
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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
Red Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 2 TOWED BY/TO.
_Artier/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE