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HomeMy WebLinkAbout2025-00073656 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 0110 ll 1111 Ifllfl I II MIIII�0 DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANV X004039514 U111 U21 3 4 1 U1 2 U2 1 U1 1 U2 1 U1 1 U2 1 5 11 u, 1 U211 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash ❑AMENDED YR 2025I 2025-00073656 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ® ❑ RELATED ®Y 0 N 11 15 2025 ®AM ❑YES ®NO U1 N STATE ST Elgin 03:39 _ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m FT/MI N E S W KIMBALL BALL ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n ❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0 g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) 2 n Y N 0 4 / yr 13-UNDER CARRIAGE ©,I �:. 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m F 9 3 ❑Y ®Nn 15-OTHER SYSTEM VEH. ATCRASHD 99-UNKNOWN 916•TOP 3 `Distraction Value 9 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S, its 4 COM VEH 0 j$J 1 0 ~ ELGIN I L 60120 0 1 0 FIRST CONTACT 12 7_;1 _5 *IIYes.See Sidebar Ut ZEU21456 IL 2026 REAR TELEPHONE IL D 1 G 1 ZE5ST8G F172998 First Chicago Insurance C ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR . 1 ID Almanza Cintora. Rosa ILS1216868-00 1 r 5HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER r RESPONDER ( XI m g DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 II/AV 0 IeGV 0 DV '1 9 6 5 Toyota Camry 2015', 00-NONE 'o,1 t2 (,-2 FIRE DUE O CRASH D ® U2 2 C o yr 13-UNDER CARRIAGE Ti M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X ❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN *0istracton Value 9 4 POINT OF 8 i 4 COM VEH D ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 5 FIRST CONTACT 6 O7 ,�=QOS •It Yes.See Sidebar C Z Schamburg IL 60194 0 1 0 EB39486 IL 2026 IAR0 Si) D IL D 4T1 BD1 FK8FU162502 Allstate ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same 979531232 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER u1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) 1 3 05 / , D / / 2 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 /15 /2025 03 39 ®❑PM in a Work Zone? ®N DIRP co 1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C) 0 2 ❑ 28 03 / / ❑PM ❑Construction * R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 U2 —a, ARREST NAME De La Torre. Marilyn 11-601 748285 / / ❑❑PM ❑Maintenance SL MT o U1 ® 11 1 ❑Utility MI CITATIONS ISSUED ❑PENDING rnN SECTION CITATION NO. ROAD CLEARANCE TIME AM t 2 El ARREST NAME De La Torre. Marilyn 6-101-A 748286 11/15 /2025 04 50 M PM 0 Unknown work zone type U1 35 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 35 1554-Wagener.Vincent 601 12 / 12/2025 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 �x 1. Has a weight rating more than 10,000 pounds(example:truck or truck/trailer -< r }----r----, - r combination):or -1 ,a�vsi INDICATE NORTH C \ \ BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } \ 0 - } r (example:shuttle or charter bus):or X L 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O © C� I. } } transporting employees in the course of their employment(example:employee \ .o transporter-usually a van type vehicle or passenger car):or C L -----------; - •} } } 4. Is used or designated to transport between 9 and 15 passengers,including the driver, N \ for direct compensation(example:large van used for specific purpose):or L L____a____� 0 i i L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m c�' placarding(example:placards will be displayed on the vehicle). D /' a,M CARRIER NAME Z / ADDRESS 'n V) \ \ CITY/STATE/ZIP 0 \ ` \ i. i. i. i. MOTOR CARR.ID 0 Interstate ❑ Intrastate r ; ❑ Not in Comm./Govt. 0 Not in Comm./Other --- --1 USDOT NO. ILCC NO. m XI Source of above z . Were HAZMAT placards on vehicle? 0 Yes 0 No = If Yes,Name on placard O 4 digit UN NO. 1 digit Hazard class No. XI XI 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? A ❑ Yes II El Unknown C 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 VIM 1 m co 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 Gray Gray u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO. _Arties/Owners Residence . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO: DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE