HomeMy WebLinkAbout2025-00068501 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) El B Injury and/or Tow Due To Crash
0 AMENDED YR 202512025-00068501 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
® ❑ RELATED ®Y 0 N 10 20 2025 ®AM ❑YES ®NO U1 -<
BIG TIMBER RD Elgin 08:06
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FT!MI N E S W N STATE ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 2 fA
❑ Kane HIT ❑Y ® N WITH VEHICLES INVLD El STOPPED U2 —I
El AT RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑NW ❑ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C)
0 3 /
yr Q -
13-UNDER CARRIAGE 1a i 2 FIRE ❑ al E
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 O m
M 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 76.TOP 3 _
0 N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 7 :il a 4 COM VEH ❑ Ea 1 0
~ ELGIN I L 60120 0 1 FIRST CONTACT 12 7_; _5 *IIYes.See Sidebar U1
Z430AC618 IL 2026 Ismi
TELEPHONE
IL D 55SWF8HB9JU243594 Bristol West ❑Y ®N U2 13 , m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Garcia. Rosa. M. GO1 6711975 00 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ❑ N 2 ou
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g DRIVER ❑ PARKED 0 DRIVERLESS ❑ FED 0 PEDAL 0 EWES 0 m v 0 i v 0 Dv
/1 9 6 3 Dodge Ram 3500(pickup) 2023 00-NONE i1_"j t2--_, DUE TO CRASH ❑ ® 98 x
.. 13-UNDER CARRIAGE 10'I !. 2 FIRE ❑ El U2 C
M 2 4 ❑Y El SYSTEM IN ENGAGED 15-OTHER 9,16-TOP 3 0 X
N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istracllon Value
s 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF
& COM VEH D ® U1 CO
FIRST CONTACT 7 O7 -5 •If Yes,See Sidebar
WEST CHICAGO IL 60185 0 1 201913E IL 2026 REAR 0 Si)
IL D 3C7WRLEL5PG576986 Federal Mutual ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Sullivan.John 1843251 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND 0 N U1 =
(UNIT) (SEAT) (DOE) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 4 10,20 /2025 08 06 ®❑pM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 8
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
o"
2 ❑ 28 10 / / ❑Plo ❑Construction
R 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS8
ARRIVED TIME
❑AM ❑Maintenance U2
a1 ® 11 4 ARREST NAME Amaro Garcia. Emilio. D. 11-601-Ax 414-1076 / / El PM SLMT
o N •
0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility
El r 2 ❑ ARREST NAME AM
x 40
7 / / PM ❑Unknown work zone type U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME co
®AM Workers present? ❑Y 40
41 4-Lara. Saul 501 11 / 18,2025 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
f -<
' 1. Hasa weight rating more than 10,000 pounds(example:truck or truck trailer
i J J combination):or
�----r----, - I.J J INDICATE NORTH p1
` W_ - 1 ` W a used r designed to transport more than 1 passengers including driver BYARRO 2 Is or ig ed transpo 5 sse rs' udin the i C
J J - r r r (example:shuttle or charter bus):or n
A _ J 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O
p n..o.rwy i - } I• . transportingemployees In the course of their employment
pbyment(example:employee
! transporter-usually a van type vehicle or passenger car):or C
L L.___a__ N.;
•4. Is used ordesi natedtotrans rtbetween9and15passengers,induding[hedrNer,
} } } for direct compensation(exam :large van used for speific purose):or
L -a-___. V
i i i L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires •u
placarding(example:placards will be displayed on the vehicle). XI
m
J CARRIER NAMErr � __ ADDRESSDICITY/STATE/ZIP n
i J / - i. i. i. i. MOTOR CARR.ID ❑ Interstate ❑ Intrastate O
❑ Not in Comm./Govt. ❑ Not in Comm./Other 0
�I. ------1 USDOT NO. ILCC NO. C
m
XI
Source of above 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
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
White White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO.
_Adieu/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY1T0:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE