HomeMy WebLinkAbout2025-00070897 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$500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) El B Injury and/or Tow Due To Crash
0 AMENDED YR 202512025-00070897 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED ®Y 0 N 10 31 2025 ®AM El YES ®NO U1
ST CHARLES ST Elgin 06:50
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FT!MI N E S W DWIGHT ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 2 fA
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 uuv 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C)
0 8 /
yr Dodge Ram 1500(pickup) 2009 00-NONE „_. 12 `_� DUE TO CRASH ® ❑
13-UNDER CARRIAGE ) I! FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED 0 0U2 0 m
M 2 SYTM 4 ❑Y ®SNE DUNK VEH. O AT CRASH 0 15-99-UUNKNOWN THER9 16•TOP�3 *Distraction Value 9 ALGN
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r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ it 6 jl COM VEH 0 El 2 O
~ ELGIN I L 60120 0 1 FIRST CONTACT 3 7_• -_5 *II Yes.See Sidebar Ut
Z FN97826 IL 2009 E
TELEPHONE
IL D 0 4A3AK24F79E040582 none ®Y 0N U2 m
.5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire Same none 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 2 ou
g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0 i v 0 Dv
'1 9 5 8 Dodge Ram 1500(pickup) 2011 00-NONE 11_"1 Qr O DUE TO CRASH ❑ 2 x
o 13-UNDER CARRIAGE 10( I 2 FIRE 0 ® U2 C
M 2 4 SYSTEM IN 0 ENGAGED 9 15-OTHER 9 1,6-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-it 6 1l, COM VEH D ® U1 CO
FIRST CONTACT 1 7� -5 •If Yes.See Sidebar
1... FIRST
IL 60123 0 1 3204053B IL 2025REAR 0
IL D 0 3D7JB1 ETOBG612792 Progressive ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Elgin Fire Same 972468150 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND❑N u1 =
(UNIT) (SEAT) (D08) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)/(TELEPHONE! (EMS) (HOSPITAL)
1 3 05 / F 2 4 0 1
m
/ / #OCCS >
71
/ / UI 2 m
/ / 1 0
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 4 10,31 /2025 06 50 ®❑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 C)
v 2 ❑ 2 28 10,31 /2025 07 12 ❑PM ❑Construction >E
R 3 0 zi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
z J ®AM ❑Maintenance U2
a u 1 ® 11 4 ARREST NAME Ferrer-Martinez. Romy 3-707 260-01768 10/31 /2025 07 17 ❑PM' ❑Utility SLMT
ISI CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM
r 2 ❑ ARREST NAME Ferrer-Martinez. Romy 11-305 260-01767 10/31 /2025 07 22 0 PM ❑Unknown work zone type U1 30
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
260-Sheehan.Joseph 401 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
1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
} } ' ' I - r INDICATE NORTH combination):or .Z-1
Not To Scale ( BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
L
C19I } ,. (example:shuttle or charter bus):or 0
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El 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
} } } transporting employees In the course of their employment(example:employee 73
D transporter-usually a van type vehicle or passenger car):or w
L L.___a____.Il 4. Isusedordesinatedtotrans rtbetween9and15 passengers,including N
} } for direct com nation exam I lar a van used for s �cifice ur o ):or the driver,
Pe ( P 9 Pe p pose):or O
, ,
< .I. i�:.__:1- L } } L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires M
- — — — , placarding(example:placards will be displayed on the vehicle). ,Zmt
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CARRIER NAME Z
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�-'''',Z, - , ADDRESS O
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1 I f ® CITY/STATE/ZIP 0
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
-"--------1 - USDOT NO. ILCC NO. rn
XI
Source of above Z
xi
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z
own tank)? 0 Yes 0 No 0 Unknown
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes ❑ No 0 Unknown g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash?El❑ Yes II No 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
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LOCAL USE ONLY TRAILER VIN 2 m
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TRAILER WIDTH(S) 0-96" 97-102" >102' T
TRAILER 1 0 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Gray Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
Arties/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE