HomeMy WebLinkAbout2025-00074981 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑5501-51,500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) (83B Injury and/or Tow Due To Crash
0 AMENDED YR 202512025-00074981 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 71
CENTER ST Elgin06:00
® ❑ RELATED ®Y 0 N 11 21 2025 ❑AM ❑YES ®NO U1
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION ITT
FT N E S W DIVISION ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 15 u)
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EDUCE ❑NW ❑ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0
1 0 FOR DAMAGEDAREA(S) FROM T TOWED U1 O
NAME(LAST,FIRST,M) Lopez Constanza.Yokari.Y. mo Nissan Rogue 2016 OD-NONE
DUE TO CRASH ® ❑! ! yr 1t. 1z
13-UNDER CARRIAGE 101 O 2 FIRE ❑ al
4
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ]$I U2 <<Tl
F 2 SYSTM 8 ❑Y ONE DUNK VEH. O AT CRASH 0 99-U15-UNKNOWN THER9 76•TOP�3 *Distraction Value ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 ;• i� s II COM VEH 0 ga 1 0
F• Elgin IL 60123 C 1 0 FIRST CONTACT 4 7 ;- -_5 *IIYes.See Sidebar U1
Z 9 DQ88608 IL 2026
TELEPHONE
IL D 0 KN MAT2MV4G P694593 Safeway Insurance ❑Y Il N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire Same 39134691 LPP005 1 r
"o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Provena St.Joseph ❑Y ® N 2 GC)
m E{ DRIVER ❑ PARKED ❑DRIVERLESS ❑ FED ❑PEDAL ❑EWES ❑row 0 e v ❑Dv
yr Jeep(after 196,)nmander 2006 00-NONE O, 0i.O DUE TO CRASH p 2
0 13-UNDER CARRIAGE 10 1, 2 FIRE 0 ® U2 C
M 2 4 SYSTEM IN 1 ENGAGED 0 15-OTHER 9 16-TOP 3 X
❑Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s_i S 1� 4 COM VEH ❑ ® U1 CO
FIRST CONTACT 12 Y._:�_, =5 •If Yes.See Sidebar C
Z Carpentersville IL 60110 0 1 0 493597 IL 2026 I 0 fp
D
IL D 0 1J8HG48K76C342895 Direct Auto Insurance ®Y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Same 160704 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (0051 (SEX) {SAFT) (AIR) (INJ) 1(EJCT( (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)(TELEPHONE) (EMS) (HOSPITAL)
1 3 03 /
/ / UI 2 D
/ / 2 O
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ID U2 Z
N 1 ® 11 4 11 r 21 l2025 06 00 ®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 5 n
T
o"
2 ❑ 2 99 I / ❑PM. ❑Construction
1
R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
—a, ARREST NAME Lopez Constanza.Yokari.Y. 11-902 482000602 ! r ID PM SLMT
o u 1 ® 11 4 CITATIONS ISSUED 0 PENDINGTIME • ❑Utility
o N SECTION CITATION NO. ROADCLEARANCE 0 AM 30
t 2 El ARREST NAME Dimas.Jose.A. 3-707 482000601 r r pM 0 Unknown work zone type U1
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 0 AM Workers present? ❑Y 30
482-Flentye.Jeremy 1o1 01 ,06/2025 01 30 ®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 truckrtrailer -<
` ` --I -' r INDICATE NORTH combination):or .Z-1
` I I L ® - 1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
(example:shuttle or charter bus):or n
3. Is designed to carry15 or fewer passengers and operated a contract carrier O
}_---------i
re j } } 1. transporting employee In the coursee of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or CO
L 4. Is used or designated to transport between 9 and 15 passengers,including N
}-----;----; ; ; - } } } g Po passen rs,indudi the driver,
I I r�l u�rana for direct compensation(example:large van used for specific purpose):or O
$ fff _ t i. i. t 5. Is anyvehicle used to transport anyhazardous material(HAZMAT)that requires
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rn
-��1,w,J placarding(example:placards will be displayed on the vehicle). XI
ux, D I CARRIER NAME Z
�""'� _ ADDRESS O
Not To Scale I T.
C)
CITY/STATE/ZIP o
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other
----- ----1 - USDOT NO. ILCC NO. m
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 VIM 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 ❑ o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Black Silver
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 ® Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE