HomeMy WebLinkAbout2025-00066680 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 1011011001 001
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003989762-
u, 9 U21 1 1 1 U199 U2 1 u1 99 u2 1 u,99 U2 1 1 14 U1 99 u2 1 *P0119*
INVESTIGATING AGENCY DAMAGE TO ANY El 5500 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 0 ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500
®NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00066680 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 -n
BLUFF CITY BLVD Elgin01:50
® ❑ RELATED ❑Y ®N 10 11 2025 ❑AM ❑YES ®NO U1
_ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION m
FT!MI N E S W S LIBERTY ST COUNTY PROPERTY El ® N DOORING ❑y #OF MOTOR ❑SLOW 15 u)
❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD ❑ STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
! ! FOR DAMAGEDAREA(S) FRONT TOWED U1 Q
Unknown.O. Unknown Unknown 00-NONE it. 12 , OUETOCRASH ❑ EN
NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE CR
161 !!. 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 2 m
SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3
9 9 ❑Y ❑N ❑UNK VEH. AT CRASH ®-UNKNOWN `Distraction Value ALGN =
s 4 COM VEH 0 Ea r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _,I[6 !i,_ 1 0
~ 0 9 0 FIRST CONTACT 99 7_; _5 *II Yes.See Sidebar U1
REAR
2 Z ' E
M TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1
NIA ❑Y ❑N U2 13 . m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same NIA 1 I-
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Refused ❑Y ❑ N 99 0
x DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑ ivy 0 Ncv ❑DV
!1 9 yf 6 Chevrolet Trax 2019 00-NONE O,' 12 "_, DUE TO CRASH ❑ ! l 2 x
0 13-UNDER CARRIAGE 10 I 2 FIRE 0 El U2 C
Ti
F 2 4 SYSTEM IN 9 ENGAGED 9 15-OTHER 9,16-TOP 3
❑Y ❑N ®UNK VEH. AT CRASH 99-UNKNOWN *Oistrac on Value 9 9
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s-it 6 11:, 4 COM VEH 0 ® U1 W
FIRST CONTACT 11 7� , 5 •If Yes.See Sidebar
E LG I N IL 60120 0 1 0 BF91903 IL 2026 I:EaR 9
IL D 3G NCJ NSB5KL178554 State Farm ❑Y J N RDEF M
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 X
Same 2185104-sfp-13 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND 0 N u1 =
KNIT) (SEAT) (DOB) (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
u 1 ® 11 1 10,11 /2025 02 49 ®PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
Fic 2 0 15 18
N 3 0 0 CITATIONS ISSUED 0 PENDING + ! ❑PM• ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 3
—a, ARREST NAME / / 0 PM '
o N ® 11 1 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
SLMT
30
t 2 0 ARREST NAME AM
7 1 r ❑❑PM 0 Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 — ❑AM Workers present? ❑Y 30
560 Martirez.Samantha 401 , ! 0 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: D
T�i�_ z
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer
i- }----r----; I } combination)or
INDICATE NORTH
1 BY ARROW• 2 Is used or designed to transport more than 15 passengers including the driver C
(example:shuttle or charter bus):or 0
3. Is designed to carry15 or fewer passengers and operated I �
a contract carrier O
I- I- -A- --i `
I - } } } transporting employee � �In the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or w
C
L }-----}----; - I. } } } •4. Is used or designated to transport between 9 and 15 passen including the driver,
cific purose):or
O
i. i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
tetot+a1tr7r3ttap 1 placarding(example:placards will be displayed on the vehicle). XI
I CARRIER NAME
- ADDRESS 0
I
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate 5
0
1 I r 1 I ❑ Not in Comm./Govt. Not in Comm./Other
• I • ,
USDOT NO. ILCC NO.
Not To Scale m
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
co
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
Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 9 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE