HomeMy WebLinkAbout2025-00073924 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
0110 111110111 Ill III III 11011
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004033
u, 1 U21 2 4 1 U1 2 U2 1 U, 1 u2 1 U, 1 u2 1 4 15 U1 1 u2 1 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY El 5500 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 51,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 2025I 2025-00073924 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIPINTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1
WALNUT AVE Elgin 04:28
® 0 RELATED ®Y ❑N 11 16 2025 ❑AM ❑YES ®NO U1 -<
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION MFT!MI N E S W J EWETT ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR El SLOW 1 (n
❑ Kane HIT ❑Y ® N WITH VEHICLES INVLD El STOPPED U2 —I
El AT RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0
Qg3 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 2 n
FOR DAMAGED AREA(S) FRONT TOWED U1 Q
NAME(LAST,FIRST,M) Barrera.Osvaldo 0 0 1 / /1 9 9 6 Mazda CX9 2007 00-NONE 11 O'I_1 DUETOCRASH ❑
13-UNDER CARRIAGE 10 , 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ ]$I U2 2 r11
M 2 4 ❑Y ®N
SYSTEM
0 UNK VEH. AT CRASH 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 7 iL 6 I,.4 COM VEH 0 0 1 0
~ ELGIN I L 60123 0 1 0 FIRST CONTACT 12 7_) _5 *II Yes.See Sidebar Ut
Z EY27916 IL 2026 REAR
TELEPHONE
IL D J M3TB28Y870114245 AAA ❑y ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire Same AUT702015676 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y El 2 ou
N DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 ivy 0 NOV 0 Dv
/1 9 6 5 Toyota RAV4 2024 00-NONE ,i_' 12 "_1 DUE TO CRASH ❑ C 2
0 13-UNDER CARRIAGE o I 2 FIRE 0 ® U2 C
c
F 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 016•TOP 3 X
0 Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i 6 i.�,_4 COM VEH ❑ ® U1 CO
F,,, FIRST CONTACT 9 7 _,__5 •If Yes.See Sidebar C
ELGIN IL 60120 B 1 0 EX72561 IL 2026 I0 N
M
IL D 2T3A1RFV1RC393560 State Farm ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
South Elgin Fire Same 1573220-SFP-13 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Provena St.Joseph RESPONDER
U1 =
(UNIT) (SEAT) (DOB) (SEX! {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 6 06 /
LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y
N 1 ® 11 1 11 ,16 /2025 04 28 ®AM in a Work Zone? ®N DIRP co
1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 2 99 11!16 /2025 04 50 0 pM 0 Construction *
R 1 O ❑ xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
3 ❑AM ❑Maintenance U2
o ® 11 1 ARREST NAME Barrera.Osvaldo 11-901-A 1552000224 11/16/2025 05 00 Igi pM SLMT
o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' El Utility
r 2 El ARREST NAME 1 1/16 /2025 05 25 ®PM 0 Unknown work zone type U1 0 AM
40
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 1552-Thompson.Ahmad Rashad 701 269-Mendiola 12 / 16/2025 01 30 0 PM Am Workers present? ®N U2 40
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 truckrtrailer -<
--:-- - j-1 - i.,row,ma [... 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
3. Is designed to carry15 or fewer passengers and operated a contract carrier O
- I. } 1- transporting employee � �In the course of their employment(example: �employee X
transporter-usually a van type vehicle or passenger car):or w
i. •}- r I!i - 1: } 1. •4. Is used or designated to transport between 9 and 15 passengers,including the driver, N
r'l v for direct compensation(example:large van used for specific purpose):or
L L--_-a-___. — — — _ — — — t i I 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
I a placarding(example:placards will be displayed on the vehicle). ;p
unit: _ -I
T - CARRIER NAME
ADDRESS 'n
D
1 COrn
Not TO Scale clTY STATFJZIP n
g
MOTOR CARR.ID 0 Interstate ❑ Intrastate
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
----------1 - USDOT NO. ILCC NO. rn
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?
❑ Yes II No ElUnknown A
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' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Gray Gray
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 DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE