HomeMy WebLinkAbout2025-00065111 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV XO03'983268
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
❑AMENDED YR 202512025-00065111 VEHT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 —n
® ❑ RELATED ®Y 0 N 10 04 2025 ®AM El YES ®No U1 —<
N G EN EVA ST Elgin 11:52
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION Ill
FT!MI N E S W E GH ICAGO ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR IR SLOW 1 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL ❑EWES ❑NIAV ❑!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
0 5 /
yr
Chevrolet Traverse 2015 00-NONE 0. 12 _ DUE TO CRASH ® ❑
13-UNDER CARRIAGE FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O 2 DISTRACTED 0 0 U2 2 rn
F 2 4 SYTM❑Y ®SNEDUNK VEH. 0 ATCRASHD 99-UUNKNOWN THER O9 16-TOP 3 `Distraction Value 9 ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF Dail S �'.4 COM VEH 0 j$J 1 0
~ ELGIN I N I L 60120 C 1 0 FIRST CONTACT 1 7 ; __5 *II Yes.See&debar U1
ZCW30784 I L 2025 Ismi
TELEPHONE
IL D 0 1 G N KRG KD6FJ 108379 DIRECT INSURANCE ❑Y ®N U2 19 . m
IF. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 99 9 Same 2029881611 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Provena St.Joseph ❑Y El 2 0
p; DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 IIIAV 0 i v 0 Dv
/1 9$2 Subaru Forrester 2000' 00-NONE O I t2 c 2 FIRE TO CRASH D D U2 2 C
.. 13-UNDER CARRIAGE
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 *Oistraelion Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8
- 1:.
4 COM VEH ❑ ® U1 CO
FIRST CONTACT 11 7 _5 •If Yes.See Sidebar
z ELGIN IL 60120 0 1 0 DX93724 IL 2025 I 0 C
IL A 7 J F1 SF6351 YH724848 STATE FARM ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 0241916SFP13 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
{UNIT) (SEAT( (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
1 4 06 / M 2 3 0 1 0
m
/ / #OCCS D
71
/ / UI 2 D
/ / 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
u 1 ® 11 1 10/04 /2025 12 00 ®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
v 2 ❑ 2 06 10(04 /2025 12 10 El Pm ❑Construction >F
R 1 O ❑ xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
3 ❑AM ❑Maintenance U2
o1 ® 11 1 ARREST NAME Valladares,Azuleyma 11-901-A 1558000084 10/04/2025 12 14 Igi pM SLMT
o N
❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility
0 AM
r 2 El ARREST NAME 10/04 /2025 12 27 ®PM ❑Unknown work zone type U1 30
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1558 Lundvick.John 301 360-Yucaitis 11 /04,2025 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.
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- A combination):or
} r , - r INDICATE NORTH �1
N Not To ScaleI
BY ARROW C
2 Is used or designed to transport more than 15 passengers including the driver
6 - } (example:shuttle or charter bus):or
3. Is x
< <---- -•-•; I transporting employeened to s 5 or fewer inthe course passengers
then emand ployment operated
xample:employee
transporter 0
73
} } }
transporter-usually a van type vehicle or passenger car):or co
4. Is used or designated to transport between 9 and 15 passengers,including wwjt
< <.
-- -- i . I
} } } g po passen rs,indudi the driver,
� '` l --- ) . . for direct compensation(example:large van used for specific purpose):or
-, uror z- l. i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). ;p
—I
CARRIER NAME Z
ADDRESS 'n
O
CITY/STATE/ZIP C)
MOTOR CARR.ID 0 Interstate ❑ Intrastate
I r1 ir .--- ....---.
❑ Not in Comm./Govt. 0 Not in Comm./Other
--- --1 USDOT NO. ILCC NO. m
XI
Source of above z
. MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No z
Form Number 0
m
Xl
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
to
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
Blue Silver
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 1 TOWED BY/TO.
Redmons/Owners Residence . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE