HomeMy WebLinkAbout2025-00071158 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00071158 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 I
300 S MCLEAN BLVD Elgin12:03
® ❑ RELATED ❑Y ®N 11 01 2025 ❑AM ❑YES ®NO U1 -<
PRIVATE mo /day/yr ®PM FLOW CONDITION m
_
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ FT/MI NESW Kane HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD DO
U2 --I
❑ 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 Nuv 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 5 C)
R20f4r TOWED U1 Q
NAME(LAST,FIRST,M) Rivero Bravo. Ninoska.A. mo
13-UNDER CARRIAGE 10 ' 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 5 M
F 2 SYTM IN ENGAGE15-OTHER
4 ❑Y ®S NE DUNK VEH. 0 AT CRASHD 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ ;iI 6 4 COM VEH 0 j$J 1 n
I— FIRST CONTACT 12 7__,--_,__S *lIVes.See Sidebar U1 0
Z ELGIN IL 60123 0 1 0 DM44155 IL 2025 REAR
TELEPHONE
IL D 0 2T3A1 RFV8SC548532 Tokio Marine American Ins ❑Y ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Elgin Toyota CA6401603-15 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER
98 c
m x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 r uv 0 Ncv 0 Dv
!1 9 yf 6 Chevrolet Cruze 2012 00-NONE ,ill 12 :_y DUE
OCRASH 0 ® U2 2 C
o 13-UNDER CARRIAGE II
c
❑Y 10 N DUNK VEH. AT CRASH 99-UNKNOWN O Oistracton Value D 9 ® U1 9 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S i 6 1' 4 COM VEH
FIRST CONTACT 3 7u1 -S *IfYes,See Sidebar
H ELGIN IL 60123 0 1 0 FB68698 IL 2025 REAR 9 N
M
IL D 0 1G1 PF5SCOC721 91 12 Bristol West Ins ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same G01680718400 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER
u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 1 11 ,01 l2025 12 03 ®AM in a Work Zone? ®N DIRP co
1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 2 n
T
0
2 ❑ 2 99 + / 0 PM• ❑Construction *
R 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
oEl 11 1 ARREST NAME Rivero Bravo. Ninoska.A. 11-902 1538000336 / ! El PM SLMT
S' N 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
30
r 2ARRESTNAMEAM
T ❑PM ❑Unknown work zone type U1
El / / ❑
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ 1538-Estrada. Leticia 600 360-Yucaitis 12 ,02,2025 01 30 ®PM Workers present? ®N U2 30
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 -<
r INDICATE NORTH combination):or p0
Not To smio I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
j. - } (example:shuttle or charter bus):or
X
LA 3. Is desgned to carry 15 or fewer passengers and operated by a contract carrier I O
a } } } transporting employ lly a v In the cvehic of van type vehicle theirpassengerr employment(example:employee w
L }---- ----; _J jJ - I. } } } transporter sed or des gnated to transport betwee 9 a d 1 passen rs,including the driver,
C
for direct compensation(example:large van used fors cific purpose):or O
' L____a____. — 16!:,,- "- --- - t } } i. _ 5. Is any vehicle used to transport anyhazardous material(HAZMAT)thatrequires
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1 j placarding(example:placards will be displayed on the vehicle). ;p
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CARRIER NAME
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1 1 i 1 ADDRESS 0If
2711+e+ wl CITY/STATE/ZIP 0
MN
MOTOR CARR.ID 0 Interstate 0 Intrastate
1 I r 1 J ❑ Not in Comm./Govt. 0 Not in Comm./Other
--'-------1 - USDOT NO. ILCC NO. rn
XI
Source of above z
. ❑ Yes 0 No 0 Unknown D
Did Carrier Safety Regulations MCS)violation contribute to the crash? A
❑ Yes II El 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
co
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Gray 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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE