HomeMy WebLinkAbout2025-00073714 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Df 2 Sheets 01111101111
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ 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$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
El AMENDED
YR 2025I 2025-00073714 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED ®Y 0 N 11 15 2025 ❑AM ❑YES ®NO U1
CONGDON AVE Elgin12:52
_ _ g PRIVATE mo /day/yr N PM FLOW CONDITION m
FTlMI N E S W BELLEVUE AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD DO
U2 —I
lgl AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FOR DAMAGEDAREA(S) FROM TOWED U1 I�
STEIN. ROSITA.C. 1 0
yr 13-UNDER CARRIAGE 10 1 2 FIRE 0 N
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
F 2 4 ❑Y ®SNEM❑ 15-OTHER
UNK VEH. O AT CRASH IN ENGAGEDO 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 0 1 0
F. FIRST CONTACT 12 7_:— ___, _5 *Yves.See Sidebar Ut
Z WAUCONDA IL 60084 0 1 0 RSTEIN1 IL 2026 REAR
TELEPHONE
IL D 0 WAUENAF44KA062826 STATE FARM ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 0591253SFP13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y El 2 0
N DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑NIAv 0 NCV ❑Dv CIRCLE NUMBER(S) U1
/20 0 6 BMW 525 2006 00-NONE 11_' 12 _, DUE TO CRASH rg ❑ 2
o 13-UNDER CARRIAGE 101 2 FIRE 0 N U2 C
c
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 0916•TOPS X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istracllon Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 0'i S l!.4 COM VEH 0 N U1 CO
Im
FIRST CONTACT 8 7 _, _5 •Iryes.See Sidebar C
ELGIN IL 60120 0 1 0 EZ61756 IL 2026 I Si)0
IL D WBANF335X6CS38018 UNINSURED ❑Y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
99 9 MEDINA.AYLIN UNINSURED BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 1 City of Elgin Stop sign.311 notified 11 ,15 ,2025 12 52 ®AM 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 C)
v 2 ❑ 150 DEXTER CT ELGIN IL 60120 2 14 , , ❑PM ❑Construction >F
1 4
R ❑ CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
3 ARREST NAME STEIN. ROSITA.C. 11-901 1558000100 / r O AM ❑Maintenance U2
o U ® 11 1 N CITATIONS ISSUED 0 PENDING SLMT
o N SECTION CITATION NO. ROAD CLEARANCE TIME
AM• ElUtilit y
t 2 El ARREST NAME M EDI NA. DI EGO 3-707 1558000101 11 115 ,2025 01 30 0 PM El Unknown work zone type U1 30
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1558-Lundvick.John 102 12 , 21 ,025 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
CO
ADDITIONAL UNITS FORMS.
r ----r•---, , ; 0A 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 -<
i- `-- -'-- --' I - ( INDICATE NORTH combination):or p0
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
!Ink s I - (example:shuttle or charter bus):or
x
L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
P.O. - . - . transporting employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
L L.___a____� 4. Is used or designated natedtotrans rtbetween9and15 passengers,rs,includingthedriver, C
Unit 2 umr 1 } } } for direct compensation(example:large van used for specific purpose):or
8 i . I t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
a ■ placarding(example:placards will be isplayed on the vehicle). 'XI
D
- CARRIER NAME Z
i r i. ADDRESS 0
ow
CITY/STATE/ZIP g
- MOTOR CARR.ID 0 Interstate ❑ Intrastate
I I T I 0 Not in Comm./Govt. Not in Comm./Other O
Not To Scale_f0 O
USDOT NO. ILCC NO.
XI
Source of above z
.
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
0
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. 0
Black Black
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT' 2 TOWED BY/TO.
Arties/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE