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HomeMy WebLinkAbout2025-00072618 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II III HH II11II IIIIII U I� II UI III I1 fli lI1DD DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X ,026994 u, 1 U21 3 4 1 U116 U2 1 U, 1 1_12 1 U, 1 U2 1 5 11 u, 1 U211 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT ❑ A 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 El OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash El AMENDED YR 202512025-00072618 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 mSUMMIT ST Elgin07:05 ® ❑ RELATED ❑Y ®N 11 09 2025 ❑AM ❑YES ®NO U1 '< _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m FT!MI N E S W N LIBERTY ST COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 1 (n ❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ® STOPPED U2 --I lgi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n FOR DAMAGED AREA(S) R20M TOWED U1 Q Jolomna. Enrique.Y. 1 0 2 0 yr0 1 Chrysler 200 2016 00-NONE , • s 0 DUE TO CRASH ® ❑ NAME(LAST,FIRST,M) q mo 13-UNDER CARRIAGE ©,I �:: FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ID 0U2 30 r<n M 2 4 ❑Y ®N SYSTEM ❑UNK VEH. O AT CRASH D O 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s,;i�a 4 COM VEH 0 j$J 1 O " �- SOUTH ELGIN IL 60177 0 1 0 FIRST CONTACT 12 T ; _-s *If Yes.See Sidebar U1 Z EZ21555 IL 2026 E TELEPHONE NA D 1 C3CCCBGSG N 105571 American Freedom ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Yat. Rogelio.J. 12244927201 2 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER 2 eu m N DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED 0 PEDAL ❑EWES 0 r uv 0 I4DV 0 DV 2 O O 0 Subaru Legacy 2022 00-NONE 10' t2 (,-2 FIRE DUE o CRASH ® U2 2 C o Yr 13-UNDER CARRIAGE c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X ❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraelion Value 9 0 POINT OF 8 i 4 COM VEH D ® U1 W N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 5 ZWorth I L 60482 0 1 0 EQ68274 I L 2026 FIRST CONTACT 6 O7 ,QI OS •byes See Sidecar 0 C Z IL D 0 4S3BWAD61 N3015334 State Farm ❑Y ®N RDEF71 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same 1684692-SFP-13 BAC $ 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 0 Y U2 Z u 1 ® 11 1 11 ,09 i2025 07 05 ®AM in a Work Zone? ®N DIRP co 1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C) o" 2 ❑ 28 99 ) ) 0 PM• ❑Construction >E Z 3 ❑ I!!I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 a 1 ® 11 1 ARREST NAME Jolomna. Enrique.Y. 11-601 1549000240 r r El PM SLMT I$!CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM• El Utility t 2 El ARREST NAME Jolomna. Enrique.Y. 6-101-A 1549000239 11)09 r2025 07 10 0 PM El Unknown work zone type U1 25 2 2 3 D OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 04 1549-Brown. Bryan 201 12 ,09/2025 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. A CMV is defined asmotor vehicle used to transportand: r ----,5-••--, ; any passengers or property Z 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -< } i.-- -i-- --; } } } r -, , ; ; , 1, ( INDICATE NORTH combination):or —I p1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } ' i 1 , } (example:shuttle or charter bus):or X 3. Is L L.___A_. 1 ..._- - J transporting edmployeeslin5 hecourseeo theire rsmployment example:employeener } } } transporter-usually a van type vehicle or passenger car):or co < <.__-a-_-_, , 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 L___-a____.: L L L ...._-..:_____� 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 --I CARRIER NAME Z ADDRESS 0 T. CITY/STATE/ZIP MOTOR CARR.ID 0 Interstate ❑ Intrastate 0 ❑ Not in Comm./Govt. ❑ Not in Comm./Other 0 USDOT NO. ILCC NO. m XI Source of above z . 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 v 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 Red White u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 1 TOWED BY/TO. Redmons/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO: DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE