HomeMy WebLinkAbout2025-00074109 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 11111111111111111 IIIIII H 11 l liii II
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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-$1,500 ®ON SCENE 1
VEHICLE/PROPERTY El OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00074109 VEHT *
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIPINTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 FI
RIVER BLUFF RD Elgin 02:51
0 0 RELATED ®Y ❑N 11 17 2025 ❑AM ❑YES ®NO U1 —<
_ g PRIVATE mo !day!yr ®PM FLOW CONDITION Ill
FT l MI N E S W MORTON AVE COUNTY PROPERTY El ® N DOORING ❑y #OF MOTOR 0 SLOW 1 cn
❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
! ! FOR DAMAGEDAREA(S) FROPtf TOWED U1 Q
Unknown.O. Unknown Unknown 00-NONE „ •
12 , DUE TOCRASH 0 NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 1 IE
01 ! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTEDU2 2 <
9 9 SYSTEM IN 9 ENGAGED 9 15-OTHER 9 16.TOP 3 0 _
❑Y ❑N ®UNK VEH. AT CRASH ®-UNKNOWN S l 4 `Distraction Value 9 ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF L 6 �i COM VEH 0 j$J 1 0
~ 0 1 0 FIRST CONTACT 12 7_; __5 *IIYes.SeeSidebar Ut
Z UNKNOWN Unknown REAR
M TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 17
UNKNOWN Unknown ❑Y ❑N U2 I-
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same Unknown 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF`Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y 0 N 99 0
m x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0
'1 9 8 4 Mercedes-Ber�300 2011 00-NONE ,�_-1 12--_, DUETO CRASH ❑ C 2
o 13-UNDERCARRIAGE 10;1 2 FIRE 0 ® U2 C
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F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3
❑Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN *Oistracl on Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 I 6 .. 4 COM VEH ❑ ® ut CO
FIRST CONTACT 6 7A- -',_5 •If Yes.See Sidebar C
ELGIN IL 60120 0 1 0 EC77581 IL 2026 PEAR 0 Si)
IL D 0 WDDGF8BB3BR171579 Teachers Insurance Compan ❑Y J N RDEF M
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Ortega.Juan.G. 65000266130103 BAC
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HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOE) (SEX) {SAFT) (AIR) (WI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
2 6 07 / F 2 4 0 1 0
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/ / #OCCS D
/ / U1 1 D
/ / 2 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 11 ,17 l2025 02 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 X
2 0 03 28
N 3 0 0 CITATIONS ISSUED 0 PENDING / ! 0 PM• ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 5
z
—a, ARREST NAME / / ❑PM '
1 ® 1 1 1 0 CITATIONS ISSUED 0 PENDING • UtilitySLMT
o N SECTION CITATION NO. ROAD CLEARANCE TIME 0
El AM
t 2 ElARREST NAME 1 1)17 12025 03 22 ®PM 0 Unknown work zone type U1 30
T
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 30
476-Ramos.Clarissa 102 - r r 0 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 -<
INDICATE NORTH p1
BY ARROW combination):or
2 Is used or designed to transport more than 15 passengers including the driver
C
_ } (example:shuttle or charter bus):or
X
-- -
- -- ---- -.i i 3. Is designed to carry15 or fewer passengers and operated a contract carrier I O
� - } } } transporting employee � �In the course of their employment(example:employee X
L -----}----; a - } transporter Is nosed or d usually designated to transpicle or ort between 9 and 15 passengers,ssen rs,including the dryer,
C
. . } for direct compensation(example:large van used for specific purpose):or
L a t : I 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
. placarding(example:placards will be displayed on the vehicle). ;p
CARRIER NAME Z
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ADDRESS
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CITY/STATE/ZIP g
Not To Scale I - i. i. i. MOTOR CARR.ID 0 Interstate 0 Intrastate
. I . . ❑ Not in Comm./Govt. 0 Not in Comm./Other
�I. ------1 - USDOT NO. ILCC NO. rn
XI
Source of above z
. ❑ Yes II 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'; ❑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
White
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