HomeMy WebLinkAbout2025-00074017 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 ,0331001
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
El AMENDED
YR 202512025-00074017 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 m
® ❑ RELATED ®Y 0 N 11 17 2025 ®AM ❑YES ®NO U1
SUMMIT ST Elgin 08:45
_ _ g PRIVATE mo !day!yr ❑PM FLOW CONDITION m
FT!MI N E S W CENTER ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 2 fA
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FOR DAMAGEDAREA(S) FROf tf TOWED U1 Q
NAME(LAST,FIRST,M) mo
!1 9 8 6 Chevrolet Equinox 2010 00-NONE 11,• ,z DUE TOCRASH ® ❑
13-UNDER CARRIAGE 101 ! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
F 2 4 ❑Y ®SNEM❑LINK VEH. 0 AT CRASH IN ENGAGE0 99-UUNKNOWN 9 76-TOP 3 ,Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 it 6 Ii 4 COM VEH 0 El 1 n
~ 60110 0 1 0 FIRST CONTACT 7 O7 _; __5 *II Yes.See Sidebar U1 0
Z DE27303 IL 2025 REAR
TELEPHONE
IL D 2CNALDEW4A6309538 Progressive ❑Y ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 995795266 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Refused ❑Y El 2 c
g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMV 0 NCv 0 DV
!1 9 6 1 FRONT TOWED
F150 2002 00-NONE 0. Q!'-O DUE TO CRASH 0 ❑ 2 x
0 13-UNDER CARRIAGE 10( I 2 FIRE ID El U2 C
c
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istrac on Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6-it 6 11:,-4 COM VEH ❑ ® U1 CO
FIRST CONTACT 12 7�_,_.6 •(ryes.See Sidebar
F... ELGIN Z IL 60120 0 1 0 4201241B IL 2025 REAR
C
M
IL D 1 FTRF17252NB98129 American Alliance ❑Y ®N RDEF M
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same I LAA109408600 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER
u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 1 11 ,17 l2025 08 45 ®❑pM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
0 2 ❑ 23 99 ( ( ❑PM ❑Construction *
Z3 ❑ DygCITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 7
o1 ® 11 1 ARREST NAME Maidi, Nadira 11-1204-B S350-650 ( ! ❑PM SLMT
o N ElCITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
❑AM
t 2 ❑ ARREST NAME Alfaro Castellanos, Matilde 6-101-A S350-651 ( ! ❑PM El Unknown work zone type U1
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
350-Farrell, Heather 102 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.
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 ` -'- ' r INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
_ (example:shuttle or charter bus):or
OC
°s° L Not To Scale 5 ry passen ers and o rated a contract career O
T I Is f netl tp car 1 n fewer
I. } } } transporting employees In the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or CO
4. Is used or designated to transport between 9 and 15 passengers,including rCjt
} } } g po passen rs,includi the driver,
s,,,,,, , ,'; -_,,r-`r for direct compensation(example:large van used for specific purpose):or O
L L a _.____ ___ — — — 'l-■u4ns — — — _ l. i I 5. Is any vehicle used to transport an hazardous material(HAZMAT)thatrequires
+s s placarding(example:placards will be displayed on the vehicle). m
M
1 * z
I CARRIER NAME Z
ADDRESS
D
w
I5 r.i 0
.. CITY/STATE/ZIP 0
MOTOR CARR.ID 0 Interstate 0 Intrastate
. I . . ❑ Not in Comm./Govt. 0 Not in Comm./Other
----- ----1 - USDOT NO. ILCC NO. rn
XI
Source of above z
. ❑ Yes 0 No 0 Unknown g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash?
❑ Yes 0 No ❑ Unknown 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'; 0 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
Black White
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
Arties/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO:
DUE TO ® Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE