HomeMy WebLinkAbout2025-00073516 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 10110 ll 1111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1,500 ®ON SCENE 1
VEHICLE/PROPERTY El OVER$1,500
El NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and f or Tow Due To Crash YR 202512025-00073516 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m
® ❑ RELATED ❑Y ®N 11 14 2025 DAM ❑YES ®NO U1 -<
WOLFF AVE Elgin02:19
g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W N CLIFTON AVE COUNTY PROPERTY El ® N DOORING Ely #OF MOTOR IR SLOW 1 (n
❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD ❑ STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Q83 DRIVER O PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!Cy 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
/ / FOR DAMAGEDAREA(S) FROPtf TOWED U1 0
Unknown,O. Unknown Unknown 00-NONE „ 12 , DUE TO CRASH ❑ EN
NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 10 IE
1 ! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3
9 9 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN •
$ 4 COM VEH 0 Ea r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _,I[S !i,_ 1 00
I- 0 9 FIRST CONTACT 99 7_; _5 *II Yes.See&debar U1
REAR
2 Z ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1)
unI—
known ❑Y ❑N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same UNKNOWN 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y El 99 0
0 DRIVER X. PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 141Av 0 i v 0 DV
yr _ 13-UNDER CARRIAGE 10 2 FIRE 0 ElU2 C
Ti SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR 0
SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 0
a 0 Y NJ 0 UNK VEH. AT CRASH 99-UNKNOWN *Oistrac on Value
POINT OF 8' 4 ut
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR -d�',_ COM VEH ❑ ® CO
FIRST CONTACT 1 Y -5 • •It Yes.See Sidebar
H DA51326 I L 2026 RFJ 0 N
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
4S3GKAT64H3623064 Progressive ❑Y ®N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
99 9 Moctezuma, Francisco 992406888 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
{UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
0 O
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 ,14 l2025 02 19 ®PM AM in a Work Zone? ®N DIRP D
co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 30
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 0 30 99
N 3 0 0 CITATIONS ISSUED 0 PENDING / ! ❑PM• El Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 3
z
-a, ARREST NAME / / El PM '
1 ® 1 1 1 ❑CITATIONS ISSUED ❑PENDING SLMT
o u SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utilit y
0 AM
r 2 0 ARREST NAME 11 r 14 /2025 02 19 ®PM ElUnknown work zone type U1 30
n 7 OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 30
1535 Solis• Laura 607 269-Mendiola , , ❑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••--, , I ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
} }----r___-; I _ 1. Has or more than pounds(example:truck or truck/trailer
c1. Hasa weight rating10 000 i
, -<
�N0 INDICATE NORTH Iron):
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ } (example:shuttle or charter bus):or
I Not To Scale I 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O
}} } transporting employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or co
L L.___a____� �L3C J I. I. I- I- •transporter
Is used or designated to transport between 9 and 15passen rs,includingthedriver,
C
for direct compensation(example:large van used for specific purpose):or O
t l. L I 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
, placarding(example:placards will be displayed on the vehicle). m
' A
. CARRIER NAME Z I
". ADDRESS 0
U)
I
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
------H--4. - USDOT NO. ILCC NO. C
m
cEirtiimissi 73
Source of above z
. GVWR/GCWR m
0 <10,000 0 10,000-26,000 0 >26,000 z
Were HAZMAT placards on vehicle? 0 Yes 0 No =
If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. XI
XI
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
Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 9 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE