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HomeMy WebLinkAbout2025-00069540 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I0110 1111 10 0011 lI 0 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004OO8207` u, 1 U21 1 1 1 U116 U2 1 U, 1 1_12 1 U, 1 U2 1 1 11 U1 1 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW ' Elgin Police Department ONE PERSON'S 1215501-51.500 ®ON SCENE 1 VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT) El AMENDED ElB Injury and f or Tow Due To Crash YR 202512025-00069540 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I ® ❑ RELATED ❑Y ®N 10 24 2025 ❑AM ❑YES ® PRIVATE NO U1 S STATE ST Elgin mo /day/yr 02:23 ®PM FLOW CONDITION M 050 ®/MI N E 0 W Locust St COUNTY PROPERTY ❑Y Igl N DOORING Ely #OF MOTOR 0 SLOW 4 Cl) Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUES 0 NUV 0!CV 0 DJ DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 1 n O 3 / yr 13-UNDER CARRIAGE ©, :. 2 FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 1 M M I 2 4 15-OTHER ❑Y ®N SYSTEM ❑UNK VEH. 0 AT CRASHD 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8, i�a 4 COM VEH 0 ZgJ 1 C) F. FIRST CONTACT 12 7 ;—, _5 *II Yes.See Sidebar Ut Z WoodStock IL 60098 0 1 0 EC95221 IL 2025 TELEPHONE IL D 0 1C4BJWEG5GL109531 Progressive ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same 962677777 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused 0 Y ® N 2 XI N DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NUV 0 KCv 0 DV 0 0 1 Chevrolet Express 2021 00-NONE 1("i 12 1 DUE TO CRASH ❑ 7 0 13-UNDER CARRIAGE 101 E FIRE ❑ ® U2 C c F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 iI s 4 COM VEH ❑ ® U1 CO FIRST CONTACT 6 O7 ,-{= 05 •If Yes.See Sidebar C ELGIN IL 60123 0 1 0 182707C IL 2026 iSi)0 IL D 0 1 G BOG RBP4M 1174782 Arch insurance Company ❑Y 123 N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 X 99 9 D.L Peterson Trust 71 CAB1045716 BAC $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (D00i (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 2 6 03 / ' D / / 4 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 11 1 10/24 /2025 02 23 ®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 O 2 0 03 99 / / ❑PM ❑Construction R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM 0 Maintenance U2 o ® 11 1 ARREST NAME Perez. Louisa Fernanda 11-601-Ax 1528-000313 / / El PM SLMT o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility El AM r 2 El ARREST NAME 10/24 /2025 02 30 0 PM El Unknown work zone type U1 30 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 30 1528-Rivera. Kevin 701 11 / 17/2025 01 30 ®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. Unit?#1 I N A CMV is defined as any motor vehicle used to transport passengers or property and: Z r �....�,.....� • 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< i- ;.---_r----; I INDICATE NORTH combination):or —I Un1t7H2 p1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C i_ - _ i. • • t- (example:shuttle or charter bus):or 0 Ig, 3. Is designed to carry15 or fewer passengers and operated a contract carrier I O < <.__-A-.-.� IIII r W., - y } } } transportingemployees In the courses of their employment pbyment(example:employee X transporter-usually a van type vehicle or passenger car):or Ico L }-----}----; III - } } 1 •4. Is used or designated to transport between 9 and 15 passengers,including the driver. C for direct compensation(example:large van used for specific purpose):or O L �__ _a____. i - t i. i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D placarding(example:placards will be displayed on the vehicle). m A __ D LowstTat CARRIER NAME Z ADDRESS 'n w C) CITY/STATE/ZIP g 1 MOTOR CARR.ID 0 Interstate 0 Intrastate I r • ❑ Not in Comm./Govt. 0 Not in Comm./Other ,____Y____ USDOT NO. ILCC NO. m Not To Scale i 73 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 White 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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO. DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE