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HomeMy WebLinkAbout2025-00075795 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 0110 11111011111111 lI100 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004049937* u, 1 U21 3 4 2 U1 5 U2 1 U1 1 U2 1 U1 1 U2 1 4 10 U, 4 U2 *P 0119 INVESTIGATING AGENCY DAMAGE TO ANY El 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-$1.500 ®ON SCENE 3 VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00075795 VENT ADDRESS NO. HIGHWAY or STREET NAMECITY TOWNSHIPINTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 —n 0 0 RELATED ®Y ❑N 11 25 2025 ❑AM ❑YES ®NO U1 -< CONGDON AVE Elgin10:01 _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m FTlMI N E S W DUNDEE AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 ❑ Kane HIT&RUN E Y ® N WITH VEHICLES INVLD DO U2 --I Igi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EDUES 0 NW/ 0 Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n �TOWED U1 0mo MEDRANO MARCANO.TATIANA. L. Chevrolet Spark 2014 00-NONE ©, • >2 �/DUE TOCRASH ❑ DI E NAME(LAST,FIRST,M) yr 13-UNDER CARRIAGE ��I 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 14 U2 4 <<n F 2 SYTM IN ENGAGED15-OTHER 4 ❑Y ®SNE❑UNK VEH. 0 AT CRASH 0 99-UNKNOWN 9 16•TOP 3 `Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�6 4 COM VEH 0 j$J 1 0 I= 60110 0 1 0 FIRST CONTACT 12 7_: __5 *Irves.See Sidebar U1 Z EQ47322 IL 2026 REAR TELEPHONE IL D 0 KL8CB6S93EC462363 Geico ❑Y ®N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR co GONZALEZ LEON.Alejandro. M. 6229019358 2 m `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER 2 eu N DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑m,lv 0 i v ❑Dv yr 10 12 ( E FIRE 0 ® U2 C o 13-UNDER CARRIAGE c F 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 9,45-TOPQ * X 0 Y NJ -. N 0 UNK VEH. AT CRASH 99-UNKNOWN 1 Oistractlon Value 0 N -;,CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 6 1.,(O COM VEH ❑ ® U1 FIRST CONTACT 2 7 '_, _5 •(ryes.See Si CO H debar ELGINREAR C M IL 60120 0 1 0 DZ98164 IL 2026 IL D 0 5N MZU3LBXJ H074358 Geico ❑Y ®N RDEF71 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = ARIZMENDI RODRIGUEZ.Ana. D. 6215433381 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) U2 996 r m #occs y 71 / ,, U1 1 D 1 0 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 ,25 ,2025 10 02 ®PM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 0 2 25 07 , ) 0 PM 0 Construction * R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 ❑AM 0 Maintenance U2 -a, ARREST NAME MEDRANO MARCANO.TATIANA. L. 11-305-A 476000420 / r ❑PM SLMT ® 11 1 0 CITATIONS ISSUED ❑PENDING Utility o N 1 SECTION CITATION NO. ROAD CLEARANCE TIME 0 0 AM T 2 0 ARREST NAME hi26 12025 10 45 ®PM ElUnknown work zone type U1 30 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30 476-Ramos.Clarissa 102 12 , 16,2025 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 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -< c ` -' -' r INDICATE NORTH combination):or .Z-1 mei I I BY ARROW 2 Is used or designed totran nortmorethan15 C l'....-- -• 40 _ } ,. ,. (example:shuttle or charter bus):or passengers uKluding the driver 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O i. - I. } } transporting employees In the course of their employment(example:employee transporter-usually a van type vehicle or passenger car):or CO I. : I ' } } 1. •4. Is used or designated to transport between 9 and 15 passengers,including the driver, N s for direct compensation(example:large van used for specific purpose):or L t i i L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D placarding(example:placards will be displayed on the vehicle). ,Zmr —I CARRIER NAME Z ' ADDRESS 0V) INot To Scale I CITY/STATE/ZIP MOTOR CARR.ID 0 Interstate 0 Intrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other -----------1 - USDOT NO. ILCC NO. rn XI Source of above Z . ❑ Yes 0 No 0 Unknown g D Did Carrier Safety Regulations MCS)violation contribute to the crash? ❑ Yes II No ElUnknown 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 VIN 1 m 'LOCAL USE ONLY TRAILER VIN 2 m 0 TRAILER WIDTH(S) 0-96" 97-102" >102' T 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 NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE