HomeMy WebLinkAbout2025-00074971 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets _ 01111101111
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INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 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 f or Tow Due To Crash
0 AMENDED YR 2025I 2025-00074971 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 71
® ❑ RELATED PRIVATE ❑Y ®N 11 21 2025 DAM ❑YES El NO U1 -<
S MCLEAN BLVD Elgin mo /day/yr 05:14 ®PM FLOW CONDITION m
•
®10(�!MI O E S W Fleetwood Dr COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
Kane HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD ® STOPPED U2 -I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
tg:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FOR DAMAGEDAREA(S) FROM TOWED U1 Q
NAME(LAST,FIRST,M) mo
1 9 6 6 Honda CRV 2014 00-NONE
13-UNDER CARRIAGE 11 • 12! DUE TOCRASH ® ❑
IE
•) FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED 0 0 U2 2 m
M 2 4 ❑Y ®SNEM❑ is-OTHER
UNK VEH. O AT CRASHD O 99-UNKNOWN 9 76•TOP 3 *Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ ;iI S �i 4 COM VEH 0 Ea 1 0
F. FIRST CONTACT 1 7_;1,_-_;__S *0Yes.See Sidebar U1
Z Streamwood IL 60107 0 1 0 Y916155 IL 2026 REAR
TELEPHONE
IL D 0 5J6RM4H59EL067540 THE STANDARD FIRE INSURAN ❑Y ®N U2 I'
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 6177608742031 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER
2 0 0 4 Mazda Mazdaspeed 6 2016 00-NONE 111 t2 c,�2 DUE O CRASH rg ® U2 2 C
o 13-UNDER CARRIAGE
c
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X
❑Y 0 N ❑UNK VEH. AT CRASH 99-UNKNOWN •Oistractlon Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 0'i�iI- S i1;,_4 COM VEH ❑ ® U1 CO
C
F,,, FIRST CONTACT 7 O7 �-t—_, _S •(ryes.See Sidebar
ELGIN IL 60123 0 1 0 DB47248 IL 2026 I Si)0
M
IL D 0 J M 1 GJ 1 V55G 1468509 PROGRESSIVE INSURANCE ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
99 9 Alvarado Ruiz. Esmeralda 999148888 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (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 ,21 /2025 05 14 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
v 2 0 28 99 11,21 l2025 05 51 ®pm ❑Construction >E
R 3 0 ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
z J 0 AM ❑Maintenance U2
a ® 11 1 ARREST NAME Gabriel.William.J. 11-601 1551-000250 11,21 r2025 05 53 Igi pM SLMT
o N
❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
0 AM
r 2 ElARREST NAME 1 1,21 ,2025 06 24 ®PM 0 Unknown work zone type U1 35
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? 0 Y 35
1551-Dede.Joseph 701 269-Mendiola 12 , 91 ,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
ADDITIONAL UNITS FORMS.
r ----r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
-:- ® - combing r more than pound (example:truck or truck/trailer 1. Has a weight rating10 000 5 i -<
INDICATE NORTH tion)o p3
BY ARROW 2 Is used or designed to transport more than 15 C
g sp passengers including the driver n
} I I - } (example:shuttle or charter bus):or
Not To Scale
tlfr_ 3. Is designed to carry 15 or fewer passengers and operated a contract career O
}----�;-•-•; I r�I } } } transport) em to ees In the course of their em
transporterg-usually a van type vehicle or passenger tar)(prxample:employee
L ----------+ r,• - } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver. Cco
for direct compensation(example:large van used for specific purpose):or o
L l. i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
i
placarding(example:placards will be displayed on the vehicle). XI
— — — — -- —1
CARRIER NAME Z
ADDRESS 0
CITY/STATE/ZIP
- MOTOR CARR.ID ❑ Interstate OD
Intrastate
:(*)(4>
ril ❑ Not in Comm./GaA. Not in Comm./Other
;------ --.; USDOT NO. ILCC NO. m
XI
Source of above z
. Form Number
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' -n
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Maroon 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: 3 TOWED BY/TO:
DUE TO ® Mies/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE