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HomeMy WebLinkAbout2025-00078543 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 0110 1111 IODU UU 001 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X�O68733 u, 1 U21 1 1 3 U, 4 U2 1 U, 1 1_12 1 U, 1 U2 1 1 11 U1 1 U2 1 *P 0 1 1 9* INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ElB Injury and for Tow Due To Crash YR 202512025-00078543 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn ® ❑ RELATED PRIVATE ❑Y ®N 12 10 2025 ®AM ❑YES ®NO U1 -< E CHICAGO ST Elgin mo /day/yr 08:17 ❑PM FLOW CONDITION m I 0 ® O COUNTY PROPERTY ❑Y ® N DOORING ICIV #OF MOTOR 0 SLOW 1 (n !MI N S W Bode Rd WITH VEHICLES INVLD ❑ STOPPED U2 --I El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Cook HIT&RUN ❑V ® N PEDALCYCLIST®N ® FREE FLOW # LNS 0 18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n FOR DAMAGEDAREA(S) FROM TOWED U1 0Julio.Jor e 1 1 / yr 13-UNDER CARRIAGE ©, EN I :: FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m M I 2 SY4 ❑Y ®SNE❑UNK VEH. 0 AT CRASH M IN D 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN 2 T. CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S, it S 4_5 *Ir Yes.See Sidebar U1 COM VEH 0 j$J 1 0 F. FIRST CONTACT 12 7 Z Crystal Lake IL 60014 0 1 0 FQ41157 IL 2026 I , TELEPHONE IL A 7 7FARS6H80TE058828 State Farm ❑Y Igl N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR Same 3599394-SFP-13 2 m `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER > Refused El ® N 2 0 N DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL ❑EWES 0 r uv 0 /1 9 5 8 Mitsubishi Outlander 2022 00-NONE 'o,1 t2 c,�2 FIRE DUE ID CRASH 0 ® U2 2 C73 o mo Yr 13-UNDER CARRIAGE il M 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X 0 Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 5 1 S .t. COM VEH ❑ ® Ut W FIRST CONTACT 6 O7 ,�=Q)OS •(ryes.See Sidebar C ELGIN IL 60120 0 1 0 FS25564 IL 2026aR Si)0 Z IL D JA4J4TA86NZ026100 Foremost Insurance ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same A7997640760 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER U1 = KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) DAMco AGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 11 1 12/10 /2025 08 17 ®❑PM AM in a Work Zone? ®N DIRP D 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) 0 2 28 11 ) ) ❑PM. ❑Construction * Z 3 0 lyg CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM Maintenance U2 ❑ aEl 11 1 ARREST NAME Julio.Jorge 11-601-Ax 1547000169 / / El PM SLMT o N 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility t 2 ❑ ARREST NAME AM x- 7 / / pM El Unknown work zone type 35 U1 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 35 1547-Steele.Justin 302 11 / 12 /26 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 ` --I -' r INDICATE NORTH combination):or .Z-1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C - } (example:shuttle or charter bus):or X A I- L.___a.._.� N } } } 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O transporting employees in the course of their employment(example:employee X transporter-usually a van type vehicle or passenger car):or w L ---..i.. .-; Not To Scale I - } 1- } •4. Is used or designated to transport between 9 and 15 passengers,including the driver.• C leod*�I 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 placarding(example:placards will be displayed on the vehicle). ,Zmt —1 CARRIER NAME Z C - ADDRESS um Imo) CITY/STATE/ZIP n MOTOR CARR.ID 0 Interstate 0 Intrastate 0 I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other --- --1 - USDOT NO. ILCC NO. m XI Source of above z . If Yes,Name on placard 0 4 digit UN NO. 1 digit Hazard class No. XI 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 M 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 0 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Red White 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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO. DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE