HomeMy WebLinkAbout2025-00072817 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets _ 01111101111
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1111 101 lU I 0
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004024601
u, 1 U21 1 1 1 U, 9 U216 U, 1 1_12 1 U, 1 U2 1 1 17 U123 U223 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S El5501-51.500 ❑ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 ®NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
0 AMENDED YR 202512025-00072817 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 6 -I
420 S LIBERTY ST Elgin08:55
® ❑ RELATED ❑Y ®N 11 10 2025 ®AM El YES El NO U1
_ g PRIVATE mo /day/yr ❑PM FLOW CONDITION MCOUNTY PROPERTY ❑Y 21 N DOORING ❑y #OF MOTOR ❑SLOW 1 cn
❑ FT!MI N E S W Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EDUCE ❑uuv ❑!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
0 4 !
yr 13-UNDER CARRIAGE 10l ! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 rI1
M 2 SYTHER
4 ❑Y ®SNE DUNK VEH.M IN 0 AT CRASH ENGAGED 0 99-UNKNOWN 9 76•TOP 3 ,Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 i� 6 ..4 COM VEH ❑ j$J 1 n
~ ELGIN I L 60120 0 1 0 FIRST CONTACT 5 7 ; _O •Ir Yes.See Sidebar U1 0
Z 3587330B IL 2026 REAR
TELEPHONE
IL D 1 GTR1 TEX3DZ116130 Allstate ❑Y ign4 U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 802920366 2 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ❑ N 2 0
tg DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEON. 0 EWES 0 NW 0 NOV 0 Dv
!1 Yr 9 9 7 Audi A3 2012 00-NONE 'o,� 12 (,-2 FIRE DUE o CRASH ® U2 2 C
o 13-UNDER CARRIAGE ID
c
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X
❑YNi N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistraellon Value 9 9
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-it 6 11,-4 COM VEH ❑ ® U1 CO
FIRST CONTACT 5 7 —_, 06 •(ryes,See Sidebar
ELGIN IL 60120 0 1 0 EZ63230 IL 2026 I 9
IL D WAUMFBFM6CA118779 Allstate ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 966953186 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND 0 N U1 =
(UNIT) (SEAT) (DOB1 (SEX) (SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
1 3 09 / F 2 4 0 1
m
/ / #OCCS D
71
/ / UI 2 D
/ / 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
u 1 ® 11 1 11 ,10 /2025 06 17 ®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 ,,
ai 2 0 30 18
N 3 0 0 CITATIONS ISSUED CI PENDING + ! 0 PM• 0 Construction >F
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 7
—a, ARREST NAME / / ❑PM '
S' N ® 11 1 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT
30
r 2 ARREST NAME AM
T 1 r ❑❑PM 0 Unknown work zone type U1
El
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 560-Martirez.Samantha 401 269-Mendiola , ! ❑❑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 truck trailer -<
c ` --I -' r INDICATE NORTH combination):or -I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} 0 - } (example:shuttle or charter bus):or 0
L A -N 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
C
' I. 4. Is used or designated to transport between 9 and 15 passengers,including cci'
}--- ----+ - } } } g po passen rs,includi the driver,
ro for direct compensation(example:large van used for specific purpose):or
O
__ _ i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
— — placarding(example:placards will be displayed on the vehicle). D
CARRIER NAME
Z
_ ADDRESS 0
D
Not To scale Ji. n
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
‘I. - --, - USDOT NO. ILCC NO. m
XI
Source of above z
. 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
White Blue.Dark
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 DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Other/Unknown VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE