HomeMy WebLinkAbout2025-00074363 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets II
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑5501-51,500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 202512025-00074363 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
BIG TIMBER RD Elgin 0 ❑ RELATED ®Y ❑N 11 18 2025 07:06 DAM ❑YES ®NO U1 —<
g PRIVATE mo /day/yr ®PM FLOW CONDITION IT1
FT l MI N E S W N MCLEAN BLVD COUNTY PROPERTY ❑Y ® N DOORING ❑v #OF MOTOR 0 SLOW 1 0)0 Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 Nuv 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 00 C)
0 4 /
yr Nissan Altima 2016 00-NONE
Q. Q DUE TOCRASH ® ❑
13-UNDER CARRIAGE FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O O DISTRACTED 0 0U2 00 I<T1
M 2 8 SYTM❑Y ®SNEDUNK VEH. 0 ATCRASHD 0 99-U 15-UNKNOWN THER9 76•TOP�3 `Distraction Value 9 ALGN
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r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 7 :il 6 �i,4 COM VEH ❑ j$J 1 0
~ ELGIN I N I L 60123 0 1 FIRST CONTACT 1 7.;{ _-5 C.
I/Yes.See Sidebar U1
Z EH41526 IL 2025 REAR
TELEPHONE
IL D 1 N4AL3AP4GC125512 Kemper ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 99 9 Same 12RA000022146 2 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 c
�{ DElVER ❑ PARKED 0 DRIVERLESS 0 PED ❑PEDAL 0 EWES 0!My 0 NKV 0 DV
/1 9 9 4 Jeep(after 191ngler 2015 00-NONE ,�_"j Qr-_, DUE TO CRASH ❑ 2
0 13-UNDER CARRIAGE 10( 1, FIRE 0 ® U2 C
70
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistrac on Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-iI�1-4 COM VEH ❑ ® U1 CO
FIRST CONTACT 12 7 _,:,.5 •If Yes.See Sidebar
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ELGIN IL 60123 0 1 FM11619 IL 2026
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IL D 1C4BJWDG9FL668595 LIBERTY MUTUAL ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same ASE-665067247415 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH! PASSENGERS&WITNESS ONLY (NAME)1(A.DDRESS)!(TELEPHONE! (EMS) (HOSPITAL)
1 3 02 /
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ID U2 Z
N 1 El 11 4 11 /18 /2025 07 06 ®AM in a Work Zone? ®N DIRP co
1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 7 C)
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2 0 2 99 / / 0 PM• ❑Construction
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R 3 ❑ $I CITATIONS ISSUED PENDING SECTION CITATION NO. EMS ARRIVED TIME
❑AM 0 Maintenance U2
a1 ® 11 4 ARREST NAME Jimenez Rodriguez. Luis. M. 11-902 1506-468 / / El PM SLMT
o N 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility
t 2 ❑ ARREST NAME AM
T / / pM 0 Unknown work zone type 45
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2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 45
1506-Nunez. Maria 502 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
i•____r____; 0 1_ 1. Has
atqn)ght rating more than 10,000 pounds{e le'xamp :truck ortruckrtrailer
cINDICATE NORTH -I
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Q BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} } I . r r (example:shuttle or charter bus):or
transporter C)
Not To Scale 3. Is des g ryvan15orType passengers and operated by a contract carrier
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I. } 1- transporting employees in the course of their employment(example:employee
netl-usuallytocarafewer vehicle or passenger car):or
_ m erc MeHi7ao I o _ I.
} } •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 0
L L____a____. 7 _ l. l. I I t 5. Is anyvehicle used to transport any hazardous material(HAZMAT)thatrequires m
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- pWcartling(example:placards will be displayed on the vehicle). XI
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CARRIER NAME Z
ialI ' ADDRESS D
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CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate ❑ Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
; _Y_ __1 USDOT NO. ILCC NO. m
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
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Form Number 0
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IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
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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
Black Black
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO.
_Adieu/Impound Lot Garage . 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