HomeMy WebLinkAbout2025-00079638 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111
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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 ®5501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 2O25I 2025-00079638 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 m80 TYLER CREEK PLZ Elgin 06:31
® ❑ RELATED ❑Y ®N 12 16 2025 ®AM ❑YES ®NO U1 -<
_ PRIVATE mo /day/yr ❑PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ FT/MI NESW Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
O AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS O
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0!Cy 0 Do DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FOR DAMAGEDAREA(S) FROM TOWED U1 Q
Garcia.Jeffrey. M. 0 9 /
yr . Q
13-UNDER CARRIAGE �0 i : 2 FIRE 0 NI
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL)THERDISTRACTED ❑ 0 U2 2 m
M 2 4 SYTM❑Y 0$NE❑UNK VEH. 0 AT CRASH 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S,_iL 6 4 COM VEH 0 j$J 1 0
~ ELGIN I L 60123 0 1 0 FIRST CONTACT 12 7 ; _5 *II Ves.See Sidebar U1
Z188053C IL 2026 REAR
TELEPHONE
IL D 1 GT4U PE73SF342532 State Farm ❑Y ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
1 99 9 Same 1051591-SFP-13 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ❑ N 2 0
p; DRIVER 0 PARKED 0 DRIVERLESS ❑ PED 0 PEDAL 0 EWES 0
/1 9 6 0 Honda CRV 2011 00-NONE till 12 ;,-2 DUE TO CRASH 0 ® U2 2 C
o _ 13-UNDER CARRIAGE III
c
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,19-TOPO3 * X
❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN O 0istrac on Value 9
U1 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s-.;,• 6 1( COM VEH D ® CO
FIRST CONTACT 2 7-'_, _5 •(ryes.See Sidebar
= ELGIN IL 60120 0 1 0 EL63633 IL 2025 REAR
C
D
IL D 5J6RE4H75BL063964 American Family ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
1 99 9 Same 411222432449 BAG E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused 0 Y°ND
0 N u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
2 3 06 /
UI 1 D
/ / 2 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 12/16 /2025 07 04 ®❑PM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 6
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1 C)
v 2 ❑ 2 14 12!16 /2025 07 04 ❑PM ❑Construction
R 3 ❑ ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
z J ®AM ❑Maintenance U2
- ®a, ARREST NAME Garcia.Jeffrey. M. 11-906 435000728 12/16/2025 07 08 ❑PM
oSLMT
U 11 0 CITATIONS ISSUED ❑PENDING
o N SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
AM U1 25
t 2 El ARREST NAME 12/16 /2025 07 30 M PM ❑Unknown work zone type
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 25
435-Mahan. David 501 397-Jones 01 /06/2026 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
ADDITIONAL UNITS FORMS.
r ----r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
807Tyler7Creek7Plazia! 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
c ` -'- -' - 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
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L L.__-a----1 ‘► - '� - } } } } transportinggemploo aeesl5 or fewer in the course passengers
their employment
ment operated by amp contract:employee
carrier O
••- transportr-usually a van type vehicle or passenger car):(orxample: w
•
L L.__-a-.-.J jr-y \,_ } } 1- •4. Is used or designated to transport between 9 and 15 passengers,including the driver. y
for direct compensation(example:large van used for specific purpose):or O
1 ,
< <--_-a-...1 u' - t i } } ,_ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
/
placarding(example:placards will be displayed on the vehicle). ;p
—1
CARRIER NAME Z
Not To Scale i ADDRESS O
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CITY/STATE/ZIP g
_ 1 MOTOR CARR.ID 0 Interstate ❑ Intrastate
o
0I ❑ Not in Comm./Govt. ❑ Not in Comm./Other
� "Y""1 USDOT NO. ILCC NO. 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
White Gray
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: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE