HomeMy WebLinkAbout2025-00071062 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 10110 ll 1111 fl 0000 000
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑5501-51.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT) (83B Injury and/or Tow Due To Crash
0 AMENDED YR 202512025-00071062 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1
N EDISON AVE El In 11:51
® ❑ RELATED ❑Y ®N 10 31 2025 ❑AM ❑YES El NO U1 -<
_ _ g PRIVATE mo !day!yr ®PM FLOW CONDITION MFT!MI N E S W LARKIN AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 3 Cl)
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER O PARKED O DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
FOR DAMAGEDAREA(S) FRO T TOWED U1 Q
De Jesus.Cindia.J. 0 4 /
yr 13-UNDER CARRIAGE 10 •!!�. 2 FIRE 0
IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL O4-TOTAL(ALL) DISTRACTED 0 Ea U2 2 M
F 2 SY4 ❑Y ®SNEM❑UNK VEH. AT CRASH IN n D 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR
F. POINT OF S iL i COM VEH 0 Ea 1 0
FIRST CONTACT 1 7_;—_;__5 *Irves.SeeSidebar U1
V Z Chicago IL 60625 B 1 0 BP95221 IL 2025 REAR
TELEPHONE
IL D SHHFK7H57JU220346 Statefarm ❑Y ®N U2 r 1 R
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire Gonzalez, Michael,A. 1736598SFP13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER
2 XI
p DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMV 0 KCV 0 DV
yr 13-UNDER CARRIAGE _
10;i :., 2 FIRE ID ElU2 C
o
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR C)
a SYSTEM IN 0 ENGAGED 0 15-OTHER 9..16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 g
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF O 1 4 COM VEH ❑ ® Ut W
F,,, FIRST CONTACT 7 O7 �,�-_!k1 5,=5 •It Yes.See Sidebar
3609648B IL 2026 lii g N
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
NM0LS7E72H1323488 Bristol West ❑Y J N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
GRISALES VALENCIA,John, F. G01647374400 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE:ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
1 3 05 / M 2 9 0 1
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/ / #OCCS D
71
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2Z
U 1 ® 18 1 10/31 l2025 11 50 ®PM in a Work Zone? ®N DIRP co
I I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
v 2 ❑ 28 18 10/31 /2025 11 57 ®PM ❑Construction *
R O ❑ ]$I CITATIONS ISSUED El PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
3 ❑AM ❑Maintenance U2
o ®1 11 1 ARREST NAME De Jesus,Cindia.J. 11-601 1513000903 10/31 /2025 11 59 ®PM SLMT
o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
AM U1 30
r 2 0 ARREST NAME 1 1/01 /2025 01 03 0 PM 0 Unknown work zone type
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 30
1513-Mann, Nathaniel 601 363-Vartanian 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
II1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
` ` --I -' r INDICATE NORTH comb nation):or P3
udwvwve
- — BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- } (example:shuttle or charter bus):or
X
l 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
- ------I— -.I
- } } } transporting employees in the course of their employment(example:employee X
rriEdlearet transporter-usually a van type vehicle or passenger car):or CO
L L.___a__ 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or 0
L t i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D
placarding(example:placards will be displayed on the vehicle). ,Zmt
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CARRIER NAME Z
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'�ig - MOTOR CARR.ID 0 Interstate El Intrastate 5
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1 1 1 1
- r . • USDOT NO. ILCC NO. rn
Not To Scale I XI
Source of above z
. Form Number
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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' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Gray White
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO.
Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE