HomeMy WebLinkAbout2025-00079495 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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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 ❑$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ❑OVER$1,500
El NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and f or Tow Due To Crash YR 202512025-00079495 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 71
16 N SPRING ST EIIn11:03
® ❑ RELATED ❑Y ®N 12 15 2025 ®AM ❑YES El NO U1 -<
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION I11
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ FT!MI N E S W Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ® STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Q83 DRIVER O PARKED O DRIVERLESS 0 PED CI PEDAL 0 EWES 0 NW 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
FOR DAMAGEDAREA(S) FRONT TOWED U1 O
2016 Ford Transit Connect 00-NONE DUE TO CRASH ❑ EN
NAME(LAST,FIRST,M) Garcia.Jorge. L. mo / ! yr 11-_R'O,2
13-UNDER CARRIAGE 10l • 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 m
M 2 4 ❑Y ONE❑UNK VEH. 0 AT CRASH IN ENGAGED0 99-UUNKNOWN 9 16-TOP 3 `Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 _iII 6 i}_4 COM VEH ❑ El 1 n
I- FIRST CONTACT 6 7_ L-Q, -5 *ir Yes.See Sidebar U1 0
Z ELGIN IL 60123 0 1 0 M211419 IL 2026 RFAR
TELEPHONE
IL B 7 1 FTBW2YM7GKB43617 Charter Oak Fire Insuranc ❑Y igi N U2 13 , m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
9 City of Elgin 8109160P901 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER
98 0
0 DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 row 0 KCV 0 DV
yr
0 13-UNDER CARRIAGE 10( I FIRE ❑ El U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ ® SPDR C)
SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 9 0 X
a ❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN Distraction` value
POINT OF 6 4 Ut
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 12 7-. 6 1'.5 C•OM
See Sidebar ® co
~ AT81926 IL 2026 RE 0 N
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
1 C3CCCAB3FN68394 National General ❑Y ®N RDEF XJ
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER I =
9 Hoehn.Joseph. D. 2022367892 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
/UNIT) (SEAT( i00B) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
0 O
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 18 1 co
12,15 l2025 11 03 ®❑pm AM in a Work Zone? ®N DIRP D
1 t 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 30 18 ) ! 0 PM ❑Construction *
Z 3 0 1!>I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
o1 ® 11 1 ARREST NAME Garcia.Jorge. L. 11-1402 W0486-000259 / ! ID Pm SLMT
o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility
25
t 2 0 ARREST NAME AM
T 1 r ❑❑PM 0 Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 25
486-Munoz.Jasmine 10o - 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.
A CMV is defined asmotor vehicle used to transportand:
r ----,5-••--, ; any passengers or property
Z
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
} i.-- -i-- --; } } } r -, , ; ; , 1, ( INDICATE NORTH combination):or —I
p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ' i 1 , } (example:shuttle or charter bus):or
X
3. Is
. L.___A_. 1 ..._- - J transporting edmployeeslIn5 hecourseeo theire rsmployment example:employeener
} } }
transporter-usually a van type vehicle or passenger car):or co
< <.__-a-_-_, , l• < <--_-a-___� , , , , 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or 0
L L___-a____.: L L L ...._-.�____� 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). XI
--I
CARRIER NAME Z
ADDRESS 0
T.
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other O
USDOT NO. ILCC NO. m
XI
Source of above z
. 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
v
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. w
White 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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE