HomeMy WebLinkAbout2025-00071021 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111
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INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 2025I 2025-00071021 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 �I
® ❑ RELATED ®Y 0 N 10 31 2025 ❑AM ❑YES ®NO U1 -<
KI M BALL ST Elgin08:07
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION ITl
FT!MI N E S W N STATE ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 15
❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 —I
Egl AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N O n
FOR DAMAGEDAREA(S) FROf4r TOWED U1 O
Garcia.Jeffrey. M. 0 9 /
yr 13-UNDER CARRIAGE 10 ! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 0 171
M 9 SYTHER
9 0 Y ®SNE❑UNK VEH.M IN 0 AT CRASH ENGAGED 0 99-UNKNOWNU 9 16-TOP 3 ,Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 ij 6 �I y COM VEH 0 E! 2 C)
~ ELGIN I N I L 60123 0 9 0 FIRST CONTACT 4 7_:'R-O •if Yes.See Sidebar U1 0
Z 188053C IL 2026
TELEPHONE
IL 0 1 GT4U PE73SF342532 UNK ❑Y 0 N U2 I''I
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same UNK 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
t RESPONDER 0
N DRIVER 0 PARKED 0 DRIVERLESS 0 PEO 0 PEOAL 0 EWES 0 lily 0 NO/ 0 Dv
yr Jeep(after 1968i�rokee 2014 oo-NONE t3-UNDER CARRIAGE ,� 12 DUETOCRASH 0❑ ® U2 2
o FIRE
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 1,6-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 6-iI 6 I_i, COM VEH 0 El U1 CO
FIRST CONTACT 1 Y ------5 •)ryes.See Sidebar
I.' ELGINREAR
IL D 0 1C4PJLCSXEW102842 The General ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 1 BIL8340864 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER ut =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
2 3 12 / F 2 3 0 1
m
/ / #OCCS D
71
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur El U2 Z
N 1 ® 11 4 10,31 /2025 08 07 ®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
0 2 25 99 , , 0 PM ❑Construction *
Z 3 0 I!!I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM 0 Maintenance U2
a 1 ® 11 4 ARREST NAME Garcia.Jeffrey. M. 11-305-A 1515-000765 r r El PM SLMT
igi CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' [3 Utility
8 N ❑AM 30
r 2 El ARREST NAME Garcia.Jeffrey. M. 11-402-A 1515-000764 r r ❑PM 0 Unknown work zone type U1
x -r2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 30
1515-BellEck.Stacy 601 12 ,02,2025 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.
r ----r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
Z`) 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
i- }---.r----; } combination):or —I
Not To Scale 1 INDICATE NORTH p0
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i_ K 1. ,--r - r r (example:shuttle or charter bus):or 0
IJ 3. Is designed tocarry 15 or fewer passengers and operated by a contract carrier I O
l- ------:----; r t - } } } transportingemployees in the course of their employment
-,�' . transporter- y a van vehicle or (example:employee w
_ usually type passenger car):or C
L L.___a__ 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including C} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or O
L a-- j 1 - t i. I 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). XI 1
- —1
CARRIER NAME Z
Z - ADDRESS 0
to
J 4 II I Watel rat l 0
CITY/STATE/ZIP
i
_ MOTOR CARR.ID ❑ Interstate ❑ Intrastate
r ❑ Not in Comm./Govt. Not in Comm./Other
!! ❑ C)
;_...Y. ._.; 1 USDOT NO ILCC NO. m
XI
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
to
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 Silver
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 2 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 DUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE