HomeMy WebLinkAbout2025-00073918 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X�033
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00073918 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
JEFFERSON AVE Elgin
® ❑ RELATED ❑Y ®N 11 16 2025 12,— ❑YES ®NO U1 '<
PRIVATE mo /day/yr 03:52 ®PM FLOW CONDITION m
_
�O C7!MI N E S ® Hiawatha Ave COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 fA
Cook HIT&RUN ❑V ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
(g)DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑Nuv ❑Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) 2 n
Y N
0 4 /
yr Honda Civic 00-NONE 2006 0 12 -
OUETOCRASH ❑ EN
13-UNDER CARRIAGE D) 2 FIRE 0 IE <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 0 U2 m
F 2 4 El ❑SNE®UNK VEH. 9 AT CRASH IN ENGAGED9 99-UUNKNOWN 016-TOP 3 `Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 0 i� 6 �'.4 COM VEH 0 j$J 1 n
F. Belvidere I L 61008 0 1 0 FIRST CONTACT 11 t _; __5 •If Yes.See Sidebar U1 0
Z FE16532 IL 2026
TELEPHONE
IL D 1 HGFA16836L064083 NONE ❑Y 0 N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Carranza Ramirez. Natanael. E. NONE 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET.CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 XI
N DRIVER ❑ PARKED 0 DRIVERLESS ❑ FED 0 PEDAL 0 EWES 0 l uv ❑NOV 0 Dv
yr 10 j t2 ( E FIRE ❑ ® U2 C
Ti 13-UNDER CARRIAGE
F 2 4 SYSTEM IN 9 ENGAGED 9 15-OTHER 9,16-TOPO3 X
❑Y ❑N ®UNK VEH. AT CRASH 99-UNKNOWN 0istracti n Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s-.;, 6 j( 4 COM VEH ❑ ® u1 CO
FIRST CONTACT 2 7-'_, _5 •(ryes,See SidebarC
F-
. . ELGIN IL 60123 0 1 0 EQ96029 IL 2026 REAR 0
IL D SYFEPRAE8LP097622 State Farm ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
99 9 De La Paz.Angelica 1747810-SFP-13 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE;ZIP
U1 =
(UNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
u 1 ❑ 11 1 11 ,16 �2025 03 52 ®pm in a Work Zone? ®N DIRP 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
1
2 ® 18 1 2 28
! 1 0 PM. ❑Construction *
R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM 0 Maintenance U2
-a, ARREST NAME Sierra Duran. Fernanda 11-601 SO475000676 r r El PM SLMT
o U 1 ® 11 1 CITATIONS ISSUED 0 PENDINGTIME • ❑Utility
o NSECTION CITATION NO. ROADCLEARANCE DI
-r AM U 30
t 2 El ARREST NAME Sierra Duran. Fernanda 3-707 SO475000677 t 1 PM 0 Unknown work zone type 1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 475 Williams. Brianna 201 269-Mendiola 12 ,09,2025 09 00 0 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
_ } (example:shuttle or charter bus):or
X
I- I- --I.-•--� transporting employeened to s inthe course passengers5 or fewer thir emaployment nd operated
xample:employeener
jrawiatikviL } } }
transporter-usually a van type vehicle or passenger car):or
L 4. Is used or desi nated to trans rt between 9 and 15 passengers, ng C}--- ----; - } } } g Po passen rs,includi [he driver,
for direct compensation(example:large van used for specific purpose):or
• Je ereen'euiiet2 O
L L____a____. — _ t 5. Is any vehicle used to transport anyhazardous theve l(HAZMAT)that requires
0
tm¢ra rn
p=lam "- placarding(example:placards will be displayed on the vehicle). >
CARRIER NAME Z
NOt TO Scale 1 1 I r.
ADDRESS D
to
C)
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
I r ❑ Not in Comm./Govt. 0 Not in Comm./Other
; _Y____1 _ USDOT NO. ILCC NO. m
XI
Source of above z
. IDOT PERMIT NO. WIDELOAD-; ❑Yes 0 No =
TRAILER VIN 1 m
to
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 Blue
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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE