HomeMy WebLinkAbout2025-00071905 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X0D4025061
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S 0$501-$1.500 ®ON SCENE 10
VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and f or Tow Due To Crash YR 202512025-00071905 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 m® ❑ RELATED PRIVATE ❑Y ®N 11 05 2025 12,—AM ❑YES El NO U1 -<
E CHICAGO ST Elgin mo /day/yr 01"02 ®PM FLOW CONDITION m
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�O 1C.'J!MI N E S ® Center St COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR SLOW 1 fA
Kane HIT&RUN ❑V ® N WITH VEHICLESOT,
INVLD DOSTOPPED U2 --I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
18:DRIVER t] PARKED O DRIVERLESS 0 PED 0 PEDAL 0 EDUES 0 NOV 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 02 n
FOR DAMAGEDAREA(S) FRONT TOWED U1 Q
NAME(LAST,FIRST,M) Real de Mendoza.Aurelia mo yr HyundaiSanta Fe 2010 00-NONE 11-_ 12
1 DUE TO CRASH 0 13-UNDER CARRIAGE 101 • 2 FIRE 0 NI
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 Ea U2 02 m
F 2 SY 15-OTHER
4 ❑Y ®SNE❑UNK VEH. 0 AT CRASH M IN D 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ it 6 4 COM VEH 0 Ea 1 0
~ ELGIN I N I L 60120 0 1 0 FIRST CONTACT 12 7 ;1 _5 *Ir Yes.See Sidebar Ut
Z R237951 IL 2024 Ismi
TELEPHONE
IL D 5NMSG3AB7AH381837 State Farm ❑Y ISI N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 0692169-SFP-13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y El 2 0
rg-
p DRIVER X. PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES 0 Iluy 0 NOV 0 Dv
yr 13-UNDER CARRIAGE 10,1 t2 E FIRE ❑ ® U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR n
SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP 3 0
a 0 Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN *0istraetlon Value
POINT OF 8 ) 4 U1
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6 COM VEH ❑ ® CO
F,,, FIRST CONTACT 5 7 -�Iri •If Yes,See Sidebar C
BR23646 IL 2026 I0 Si)
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
1 G 1 PC5SB7E7400310 State Farm ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Chavez.Alyssa. M. 0103664-SFP-13 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (008) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 18 1 11 ,05 ,2025 01 02 ®PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
0
2 0 28 99 / ) 0 PM• ❑Construction *
3
R 3 0 $I CITATIONS ISSUED PENDING SECTION CITATION NO. EMS ARRIVED TIME
❑AM 0 Maintenance U2
a1 ® 11 1 ARREST NAME Real de Mendoza.Aurelia 11-601-Ax 1508000786 / ! El PM SLMT
o N -
❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility
0 AM
T 2 0 ARREST NAME 11 l 05 ,2025 01 02 ®PM El Unknown work zone type U1 30
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1508-Salgiado. Leandro 101 12 , 16,2025 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 truck trailer -<
` ` --I -' r INDICATE NORTH combination):or .Z-1
COMl(!81 0 : BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ } (example:shuttle or charter bus):or
X
I uonrerk net m en. 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 X
transporter-usually a van type vehicle or passenger car):or w
L i. ..i.. ..; I. } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver, N
n for direct compensation(example:large van used for specific purpose):or O
L ' ___.I evn,,...-—del---._— - t i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
, , placarding(example:placards will be displayed on the vehicle). XI
-1
CARRIER NAME Z
ADDRESS 0
w
C)
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
--- --1 - USDOT NO. ILCC NO. m
XI
Source of above z
. -I
Were HAZMAT placards on vehicle? 0 Yes 0 No =
If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. Xl
Xl
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 0 No 0 Unknown g
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
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
Black Beige
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 1 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE