HomeMy WebLinkAbout2025-00070648 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 0110 1111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X00011239
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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 ®5501-$1,500 ❑ON SCENE 3
VEHICLE/PROPERTY ❑OVER$1,500 Ill NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00070648 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 71
RT20 WB Elgin05:00
® ❑ RELATED ®Y 0 N 10 29 2025 :km ❑YES ®NO U1
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W S STATE ST COUNTY PROPERTY El ® N DOORING Ely #OF MOTOR 0 SLOW 1 cn
❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I
CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
/ / FOR DAMAGEDAREA(S) FRONT TOWED U1 0
Unknown.O. Unknown Unknown 00-NONE „ 12 , OUETOCRASH ❑
NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 161 !!. 2 FIRE 0 (E <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 m
SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3
M 9 9 ❑Y ❑N ❑UNK VEH. AT CRASH ®-UNKNOWN `Distraction Value ALGN
$ 4 COM VEH 0 Ea r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _,I[6 !i,_ 1 00
I— 0 9 0 FIRST CONTACT 99 7_; _5 *II Yes.See&debar U1
REAR
2 Z ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1/
unknown 0 Y 0 N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same unknown 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y ❑ N 99
m x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uv 0 KCv 0 DV
!1 9 9 8 Audi A3 2015 00-NONE i1_"j Q1-_, DUE TO CRASH ❑ 2 x
...
ay Yr 13-UNDER CARRIAGE 10( l 2 FIRE 0 ® U2 C
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN *Oistracl n value 9
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-it 6 11:,-4 COM VEH ❑ ® U1 CO
FIRST CONTACT 12 7�_, .5 •If Yes.See Sidebar
H E LG I N IL 60120 0 1 0 AW49398 IL 2026 REAR 0
IL D WAUACGFF8F1012879 Magnum ❑Y ®N RDEF P3
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Morales Carrillo. Leticia 2026203693 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
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DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ®Y U2 Z
N 1 CO 11 9 10,29 /2025 10 15 ®AM in a Work Zone? ❑N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
2 ❑ 20 99
N 3 0 0 CITATIONS ISSUED 0 PENDING + / ❑PM• ®Construction
SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
—a, ARREST NAME / / El PM '
o N ® 11 5 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
SLMT
T 2 ❑ 45
ARREST NAMEAM
x- 7 ❑PM 0 work zone type U1
r / ❑
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 El ❑AM Workers present? ❑Y 45
562-Hernaindez. Myra 391-Jacobucci r / ❑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
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___ ___-I Not TO Scale I 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
' r INDICATE NORTH combination):or p0
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ } (example:shuttle or charter bus):or
ustaq 3. Is designed to carry 15 or fewer passengers and operated a contract carrier 0
A }} } transporting employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
L 4. Is used or designated to transport between 9 and 15 passengers,including C}--- ----; - } } } g po passen rs,includi the driver,
3 for direct compensation(example:large van used for specific purpose):or
O
< 5. Is any vehicle used to transport anyhazardous material(HAZMAT) requires
that t I I placarding(example:placards will be displayed on the vehicle).
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CARRIER NAME Z
ADDRESS 0
w
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I I ❑ Not in Comm./Govt. ❑ Not in Comm./Other 00
‘I. - --1 - USDOT NO. ILCC NO. C
m
XI
Source of above z
. Form Number
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Xl
IDOT PERMIT NO. WIDELOAD'; 0 Yes 0 No 2
TRAILER VIN 1 m
to
LOCAL USE ONLY TRAILER VIN 2 m
a
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
Black
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 DUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE