HomeMy WebLinkAbout2025-00075314 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 0110 1111 10 lOI11fl fli III
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004043099*
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INVESTIGATING AGENCY DAMAGE TO ANY El$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 1
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 2025I 2025-00075314 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 —n
TODD FARM DR Elgin04:06
® ❑ RELATED ®Y 0 N 11 23 2025 ❑AM ❑YES IX]NO U1
_ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION m
FT/MI MI N E S W BIG TIMBER RD COUNTY PROPERTY :IY ® N DOORING Ely #OF MOTOR 0 SLOW 3 Cl)
❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD ❑ STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C)
1 2 /
yr 13-UNDER CARRIAGE I 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ga U2 0
10. m
15-
THER
F 2 SYTM 4 ❑Y ®SNE DUNK VEH. 0 AT CRASH 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, i�6 4 COM VEH 0 j$J 1 0
~ Gilberts IL 60136 0 1 0 FIRST CONTACT 12 7 ; _5 *IIYes.SeeSidebar Ut
Z SUBAWU1 IL 2026 REAR
TELEPHONE
IL D 0 3VWC57BU5MM094061 Progressive ❑Y IlN U2 I—
IL'in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 991822107 1 1—
"6 HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 XI
x DRIVER ❑ PARKED 0 DRIVERLESS ❑ FED 0 PEER. 0 EWES 0 row
!1 9 8 6 Chrysler Pacifica 2017 00-NONE 11_' t2 "_, DUE TO CRASH 0 ❑ 2
0 13-UNDER CARRIAGE I 2 FIRE ❑ ® U2 C
li c
F 2 6 SYSTEM IN 0 ENGAGED 0 15-OTHER 016•TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *OistracIi n Value 9
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 0'i'_._ C.OM VEH D ® U1 CO
F„ FIRST CONTACT 11 7 _, _5 •Iryes.See Sidebar C
ELGIN IL 60123 B 1 0 CB32679 IL 2025 0 Si)
M
IL D 0 2C4RC1 BG7HR721920 Statefarm ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Elgin Fire 99 9 Same 1360708-SFP-13 BAG E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Sherman RESPONDER
ut =
(UNIT) (SEAT) (DOD) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((A.DDRESS)((TELEPHONE) (EMS) (HOSPITAL)
2 3 09 /
UI 1 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 4 11 ,23 ,2025 04 06 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 8
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM u1
2 28 06 11,23 ,2025 04 06 ®PM ElConstrtict on
R O ❑ gi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
3 ❑AM ❑Maintenance U2
o ® 11 4 ARREST NAME Rivera. Farah. M. 11-801 1551000253 11,23,2025 04 10 lgi PM SLMT
1g1 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME DAM• • ❑Utility
t 2 El ARREST NAME Rivera. Farah. M. 11-1427-H- 1551000253 11 123 ,2025 05 00 0 PM ❑Unknown work zone type Ut 45
2 2 3 ID ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1560-Jones. Bennett 501 12 ,09,2025 09 00 0 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
7°°° errODE 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
` ` --I -' 4 I. INDICATE NORTH combination):or -I
NBY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
} u,ya I _ } C(example:shuttle or charter bus):or 0
L L.___A.._.� I I Not To Scale 1 3. Isdesgnedto carry 15or fewer passengers and operated bya contract carrier I O
} } } transporting employees In the course of their employment(example:employee X
' 'r �prnme.rnta. transppoorterg-usuall a van type vehicle or passenger car): r CO
it
i. }-----;----; rcaq - } 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 O
L i — — — — — — t i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
• placarding(example:placards will be displayed on the vehicle). ;p
-- —1
CARRIER NAME Z
0
_ ADDRESS T.
CITY/STATE/ZIP g1 MOTOR CARR ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. ❑ Not in Comm./Other
; _Y_ _.; USDOT NO. ILCC NO. m
XI
Source of above z
. If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. Xl
Xl
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 No 0 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? 0 Yes 0 No 2
TRAILER VIN 1 m
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
White Black
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 2 TOWED BY/TO.
SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE