HomeMy WebLinkAbout2025-00075678 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II I 111 IIII
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0D4045475
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INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
El AMENDED ElB Injury and f or Tow Due To Crash YR 202512025-00075678 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I
® ❑ RELATED ®Y 0 N 11 25 2025 IMAM ❑YES ®NO U1 -<
N LIBERTY ST Elgin11:59
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FTlMI N E S W SLADE AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
Igl AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEoa_ 0 EWES ❑uuv ❑!Cy ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 C)
T TOWED U1 FOR DAMAGEDAREA(S) FROM VI E
0PI EDRA. ROSALI N DA 1 1 /
yr 13-UNDER CARRIAGE NI
101 ! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0U2 3 M
F 2 4 SYSTEM IN ENGAGED 15-OTHER 9 76.TOP 3 _
❑Y ❑N [DUNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ iI B �i COM VEH ❑ Ea 1 0
~ ELGIN I N I L 60120 0 1 0 FIRST CONTACT 1 7_; -_5 *Ir Ves.See Sidebar U1
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TELEPHONE
IL D 0 1 FM5K8DH3KGB05989 STATE FARM ❑Y J N U2 I--
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 0401041-SFP-13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 c
E{ DRIVER ❑ PARKED ❑DRIVERLESS 0 FED ❑PEDAL 0 EWES O 141Av 0 N v ❑DV
!1 9 8 7 Toyota Camry 2022 00-NONE ,� ' 12.. , DUE TO CRASH ❑ C 2
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❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istracton Value
POINT OF 8 i ' 4 COM VEH D ® U1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR O j e ��- C
FIRST CONTACT 9 7 _, _5 •(ryes,See Sidebar
n DES PLAINES IL 60016 0 1 0 EM59258 IL 2026 REAR Si)0
IL D 0 JTDKAMFU2N3174309 STATE FARM ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
99 9 TAJ AUTOMOTIVE LLC 0092931-SFP-13 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
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(UNIT) (SEAT( (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME(((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
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1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 7 n
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2 ❑ 2 28 , ! ❑PM ❑Construction *
R 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
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a PIEDRA. ROSALINDA 11-901-A 374001355 / ! PM '
r 1 ® 11 4 -ARREST NAME _ El
o u ❑CITATIONS ISSUED ❑PENDING UtilitySLMT
o N SECTION CITATION NO. ROAD CLEARANCE TIME ❑
AM U, 30
t 2 ❑ ARREST NAME 11(25 ,2025 11 59 j PM ❑Unknown work zone type
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 30
374-Rizzu-o. Michael 201 01 (06,2026 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
wauevm7sT Z
i- �____r____; til, _ 1. 10,000Has
latl0n)9ht rating more than pounds(example:truck ortruckrtrarler
INDICATE NORTH or -I
' BY ARROW c2 Is used or designed to transport more than 15 passengers including the driver C
_ } (example:shuttle or charter bus):or
Not To Scale I 3. Is desgned to carry 15 or fewer passfen ers and o rated a contract carrier O
- } } } transporting employees In the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or w
L }-----}----+ y - I. } } } 4. Is used or designated to transport between 9 and 1 passen rs,including the driver,
" " [
C
tfor direct compensation(example:large van used fors specific purpose):or
L « i. } } �_ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
` MADE/AVEm
1 placarding(example:placards will be displayed on the vehicle). XIT ,i :. : :. :__ __:.
CARRIER NAME Z
I% _ ADDRESS 0
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0
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate ❑ Intrastate
1 I r ❑ Not in Comm./Govt. Not inComm./Other
------- --1 - USDOT NO. ILCC NO. rn
XI
Source of above z
. own tank)? 0 Yes 0 No 0 UnknownT.
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 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
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LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Gray Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 1 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE