HomeMy WebLinkAbout2025-00076619 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004049918.
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INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT 0 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$1,500 ❑NOT ON SCENE(DESK REPORT) 0 B Injury and/or Tow Due To Crash
0 AMENDED YR 202512025-00076619 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 rn
® ❑ RELATED ❑Y ®N 11 30 2025 ❑AM ❑YES ®NO U1
N STATE ST Elgin07:43
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
0 !MI N E S W BigTimber Rd COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 Cn
® Kane HIT&RUN ❑V ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 --I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
18:DRIVER ❑ PARKED ❑CRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
FOR DAMAGEDAREA(S) FRONT�OUETOCRASH TOWED U1 I�
Barahona. Maria 0 1 /
yr 13-UNDER CARRIAGE 10.I 2• FIRE 0
C23STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 4 rn
F 2 SY n 15-OTHER
4 ❑Y ONM❑UNK VEH. AT CRASH IN n D 99-UNKNOWN 9 16•TOP 3 ,Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF & i�S 4 COM VEH 0 j$J 1 O
I . 60110 0 1 FIRST CONTACT 12 7 ; 5 *u Yes.See Sidebar U1
ZBY21070 IL 2026 E
TELEPHONE
IL D 5N1 ED28YX4C656738 Kemper ❑Y ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 12AU001458346 3 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER XI
Refused ❑Y ❑ N 2 c
N DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 i My 0 NDV 0 DV CIRCLE NUMBER(S) U1
!1 9 6 3 Toyota RAV4 2007 00-NONE 1 t2 c,�2 FIRE DUE OCRASH D ® U2 2 C
o 13-UNDER CARRIAGE
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X
❑Y ®N DUNK VEH. AT CRASH 99-UNKNOWN `0istraellon Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S 1 S .t. 4 COM VEH D ® Ut W
FIRST CONTACT 6 O7 ,�_ -)�•If Yes.See Sidebar C
ELG I N IL 60123 0 1 EW45720 IL 2026aR 0 Si)
IL D JTMBK33V176026111 Progressive ❑Y ®N RDEF M
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 971095431 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND 0 N U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
u 1 ® 11 1 11 ,30 /2025 07 43 ®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 0 28 18 ( r 0 PM• 0 Construction *
Z3 0 xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 5
o 1 ® 11 1 ARREST NAME Barahona. Maria 6-101 487000640 r ! El PM SLMT
MI CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME
o • 0 Utility
N 0 AM
t 2 El 35
ARREST NAME Barahona. Maria 11-601-Ax 487000639 ( r pM 0 Unknown work zone type U1
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 35
487-Heal. Kayla 501 269-Mendiola 01 (05(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
y13701?Stetent ADDITIONAL UNITS FORMS.
r ----r••--, , I A CMV is defined as any motor vehicle used to transport passengers or property and: Z
i- i•____r____; I _ combination):or more than pounds(example:truck ortruckrtrarler 1. Has a weight rating10 000 5i -<
INDICATE NORTH -I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- } (example:shuttle or charter bus):or
foa..w-mow T,
-�""�T 3. Is designed to carry15 or fewer` A g passengers and operated a contract career O
} } } transporting employees In the course of their employment(example:employee X
L -----}----; - } } } } •transporter. sed or des gnated to transport betweelly a van type vehicle or n 9 and 15 passengers,including the driver,enger car):or CO
I ! for direct compensation(example:large van used fors specific purose):or O
i. i t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
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placarding(example:placards will be displayed on the vehicle). III
;p
envmmnna _ __ _1
I CARRIER NAME Z
rl ADDRESS D
I
CITY/STATE/ZIP 0
I 0
_ MOTOR CARR.ID ❑ Interstate ❑ Intrastate
❑ Not in Comm./Govt. ❑ Not in Comm./Other 00
‘I. - --1 I r USDOT NO. ILCC NO. m
we msmexse ,
Source of above z
. -I
Were HAZMAT placards on vehicle? 0 Yes 0 No =
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 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
Black Blue
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
_Other/Owners Residence SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE