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HomeMy WebLinkAbout2025-00075015 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 0110 1111 10111110111011 DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANV X0D4040663 u, 1 U21 3 4 1 U1 4 U2 1 u, 1 u2 1 u, 2 u2 1 5 11 u1 1 U211 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY 0$500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 3 VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash 0 AMENDED YR 2025I 2025-00075015 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 :1 ® ❑ RELATED ❑Y ®N 11 21 2025 DAM YES ®NO U1 KI M BALL ST Elgin PRIVATE mo /day/yr 10:46 ®PM FLOW CONDITION III 020 ®!MI N E S © Dundee Ave COUNTY PROPERTY ❑Y 21 N DOORING Ely #OF MOTOR ElSLOW 15 u) Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ® STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ❑ FREE FLOW # LNS 0 18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEOAL 0 EDUCE 0 MAV 0 lacv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 5 C) FOR DAMAGED AREA(S) FROM TOWED U1 O NAME(LAST,FIRST,M) Suarez, Luis, H. 0 mo3 / 13-UNDER CARRIAGE 10 , 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 5 r<r1 M 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 76.TOP 3 _ ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN T CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ ;il_6 I,.4 COM VEH 0 Ea 1 O ~ ELGIN N I L 60123 B 1 FIRST CONTACT 12 7 ; _5 *If Yes.See Sidebar U1 Z FS79370 IL 2026 TELEPHONE IL D 1 MEFM10P5XW614100 Safeway Insurane ❑Y Igl N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same 4228979ILPP002 1 r "o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ® N 2 eu x DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEOAL 0 EWES 0 NMv 0 NOV 0 DV 2 0 0 4 Ford Escape 2011 00-NONE ,i_1 t2..-_, DUE TO CRASH rg ❑ 2 x o 13-UNDER CARRIAGE 16} 2 FIRE 0 ® U2 C c M 2 4SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 0 X 0 Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistrac on Value POINT OF s i 4 COM VEH ❑ ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR -II 5 1'._ FIRST CONTACT 6 Y__{_O ._5 •IfYes.SeeSidebar — Elgin IL 60120 0 1 0 ET82455 IL 2026 REAR O Si)c IL Other 1 FMCU9E71 BKB36197 American Alliance ®V ❑N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same I LAA098979900 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPOND O N u1 = (UNIT) (SEAT) (DOB1 (SEX) {SAFT) (AIR) (WI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) 2 3 07 / F 2 4 0 1 0 m / / #OCCS D / / U1 1 D / / 2 O 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 ,21 ,2025 10 46 ®PM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 o" 2 0 28 10 , r ❑PM ❑Construction >F R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM 0 Maintenance U2 o 1 ® 11 1 ARREST NAME Suarez, Luis, H. 11-601 298001341 , / ID PM SLMT igi CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility o N 0 AM 30 t 2 El ARREST NAME Chub-Xol.Wilmer, R. 6-101 280001339 , r pM 0 Unknown work zone type U1 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 30 298-Lopez, Mirko tot 12 ,08,2025 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 truck trailer -< c ` -'- ' r INDICATE NORTH combination):or .Z-1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C 1 - } r r r (example:shuttle or charter bus):or 0 :� t 3. Is designed to carry15 or fewer passengers and operated a contract carrier O } } } transporting employee in the course of their employment(example:employee ° transporter-usually a van type vehicle or passenger car):or w L L.___a____. 0 4. Isusedordesinatedtotrans rtbetween9and15 ssen rs,includingthedriver, I 0 �,n�uw� } } } for direct compensation(example:large van used for specific purpose):or 0 ' L.__-a..... - t i i _ 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires rn Ai&To Scale I gligligarlaill placarding(example:placards will be displayed on the vehicle). XI %ur,rwn99r. -- _I CARRIER NAME Z _ ADDRESS T. C) CITY/STATE/ZIP MOTOR CARR.ID 0 Interstate ❑ Intrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other ‘I. - --1 - USDOT NO. ILCC NO. m XI Source of above z . ❑ 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 VIN 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 Teal 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: 2 TOWED BY/TO: DUE TO ® Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE DUE