HomeMy WebLinkAbout2025-00069893 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 0110 �l ill ilom
�
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV XO04OQ13189`
u, 1 U2 1 1 1 U116 U2 U, 1 U2 U, 1 U2 1 1 9 U1 13 U221 *P 0119
INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT 0 A 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 ❑NOT ON SCENE(DESK REPORT) El B Injury and f or Tow Due To Crash
0 AMENDED YR 202512025-00069893 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I
® ❑ RELATED ❑Y ®N 10 26 2025 ®AM D YES ®NO U1 —<
12 S MELROSE AVE Elgin07:51
_ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 1 cn
❑ FT!MI N E S W Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
O AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Q83 DRIVER O PARKED El DRIVERLESS 0 PED O PEON. 0 EWES 0 NW 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
0 6 !
yr 13-UNDER CARRIAGE ,I ,. Z FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 2 m
F 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 16.70P 3 _
❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 7 it B ii,4 COM VEH ❑ Ea 1 0
H F.
ELGIN I L 60120 0 1 0 FIRST CONTACT 11 7_;1 __5 *Irves.See Sidebar U1
Z FG97505 IL 2026 REAR
TELEPHONE
IL D 5J6RW6H33HL008427 Progressive ®Y ❑N U2 I—
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 995673998 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 XI
m p DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEON. 0 EWES 0 Nuv 0 NCv 0 Dv
yr 10.j 12 c., 2 FIRE ❑ ® U2 1 C
o 13-UNDER CARRIAGE
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED (3)-OTHER 91 1,6•TOP 3 ❑ ® SPDR n
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istraction Value 0 -
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF �'I t 4 COM VEH D ® U1 CO
FIRST CONTACT 8 7� B li`.5 *(ryes,See Sidebar
~ CJ72076 IL 2026 I 0 Si)
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
3FAHP07127R212847 Falcon ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Munoz. Elvia 01 001 07577-1 1 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 I
(UNIT) (SEATI (DOB) (SEX) {SAFT) (AIR) OM (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 El 18 1 10,26 /2025 07 51 ®❑PM in a Work Zone? ®N DIRP co
1 F PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 ❑ 18 1 08 20
! , ❑PM• ❑Construction *
R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
— U2
a, ARREST NAME Najera, Rosa, I. 3-707 HW 747652 ! ! ❑❑PM ❑Maintenance SLMT
U 1 ® 11 1 CITATIONS ISSUED ❑PENDING • TIME • ❑Utility
o N SECTION CITATION NO. ROAD CLEARANCE AM 30
Ti 2 0 20 5 ARREST NAME Najera, Rosa, I. 11-709-A HW 747651 , , DI PM 0 Unknown work zone type U1
2 2 3 El
ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
298-Lopez, Mirko 601 11 ,21 ,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 -<
c ` -' -' r INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
z - } (example:shuttle or charter bus):or
X
L L----A--- () - } } } transporting empined to oyees Inhecourse 5 or fewer o their emplrs oy nt example:employee a contract ner X
+r+� .e. I r I transporter-usually a van type vehicle or passenger car):or
L ----------; waromv�e gnaro I - } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver, y
U -r— — rnn— for direct compensation(example:largevan used for specificor mpe n(ex mple purpose): O
L � t 5. Is any vehicle used to transport any hazardous material(HAZMAT)thatrequires m
�a ro.nay.. placarding(example:placards will be displayed on the vehicle). XI
1 I CARRIER NAME Z
r L ‘. i. ..... .....
ADDRESS 0
w
C)
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other
----------1 - USDOT NO. ILCC NO. m
XI
Source of above z
. IDOT PERMIT NO. WIDELOADo ❑Yes 0 No =
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 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Gray Black
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Mies/Impound Lot Garage 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