HomeMy WebLinkAbout2025-00078185 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
I0110
II 1111
IOU
Ifl
II IIIIIIIIII
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X4060541
u, 1 u21 3 4 1 U,99 U299 u, 1 U2 1 u,99 U2 99 1 11 U, 1 U2 1 *P 0119
INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500
El NOT ON SCENE(DESK REPORT)
El AMENDED ElB Injury and for Tow Due To Crash YR 202512025-00078185 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1
LAWRENCE AVE El In03:33
® ❑ RELATED ®Y 0 N 12 08 2025 DAM ❑YES El NO U1 -<
_ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION m
FT!MI N E S W N STATE ST COUNTY PROPERTY ❑Y ® N DOORING ICIy #OF MOTOR 0 SLOW 1 cn
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ® STOPPED U2 --I
El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEON. 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 1 n
FOR DAMAGEDAREA(S) FRONT TOWED U1 0
NAME(LAST,FIRST,M) Melendez.Jesus. I. mo0 8 / !2 0 0 5 Nissan Sentra 2025 00-NONE „ Oi_, DUE TOCRASH ❑ EN
13-UNDER CARRIAGE ,a i ' 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® 0 U2 1 r<rl
M 2 4 SY❑Y ®SNE❑UNK VEH. 0 AT CRAS IN H 0 99-UNKNOWN 9 ,6•TOP 3 `Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s iL 6 4 COM VEH 0 j$J 2 C)
~ ELGIN I N I L 60120 0 1 0 FIRST CONTACT 12 7_. _-5 *If Yes.See Sidebar U1
Z FF97433 IL 2026 E
M TELEPHONE
IL D 0 3N 1 AB8CV4SY216580 Allstate ❑Y ®N U2 m
2. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 975494790 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Refused ❑Y El 2 c
m g DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑r uv 0 NCv ❑DV CIRCLE NUMBER(S) U1
!2 O 0 6 Acura TL 2004 00-NONE ,._"j t2..-_, DUETO CRASH 0 21 2 x
oYr 13-UNDERCARRIAGE ta;l 2 FIRE ❑ ® U2 C
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraebon Value 9 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8_iI 6 I,,_4 COM VEH ❑ ® ut to
FIRST CONTACT 6 Y__{_O ._5 •IfYes,SeeSidebar C
F*. E LG I N IL 60123 0 1 0 FW54456 IL 2026 REAR 3 C/)
IL D 0 JH4CL96894C040747 Allstate ❑Y ®N RDEF .7)
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Same 802784500 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER 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 0 Y U2 Z
N 1 El 11 1 12,08 l2025 03 33 ®PM in a Work Zone? NJ 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 C)
o"
2 0 28 18 r r ❑PM• ❑Construction *
R 3 0 lyg CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMSARRIVED TIME 3
❑AM ❑Maintenance U2
a ® 11 1 ARREST NAME Melendez.Jesus. I. 11-601-Ax W1525000828 ! ! El PM SLMT
o N 1
0 CITATIONS ISSUED • ❑
PENDING SECTION CITATION NO. ROAD CLEARANCE TIME Utility
AM
t 2 El ARREST NAME 12 r 08 l2025 03 41 ®PM El Unknown work zone type U1 35
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
❑Y 35
1525-NavE.Oscar 601 391-Jacobucci r r ❑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 -<
i- }____r____; 1 } combination):or —I
Not To Scala INDICATE NORTH p3
11 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
5 - } (example:shuttle or charter bus):or
t 3. Is desgned to carry 15 or fewer passengers and operated a contract carrier O
A
} } transporting employees In the course of their employment(example:employee X
I } transporter-usually a van type vehicle or passenger car):or co
C
L }-----}----; r } } } 4. Is used or designated to transport between 9 and 15 passengers,including the driver, to
for direct compensation(example:large van used for specific purpose):or
r
L L____a____. i i t 5. Is any vehicle used to transport an hazardous material(HAZMAT)thatrequires m
Ho
ntt2 f placarding(example:placards will be displayed on the vehicle). D
1 ' CARRIER NAME Z
ADDRESS C)
O
1
t CITY/STATE/ZIPg
` - i. i. i. i. 4. MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I 1 0 Not in Comm./Govt. 0 Not in Comm./Other
, _Y____ t USDOT NO. ILCC NO. rn
m
XI
Source of above 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
to
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
Gray Black
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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE