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HomeMy WebLinkAbout2025-00079728 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 IIIIII II II 1111 III IIIII 1111 I III IIIDRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0040 1062 u, 1 U21 2 4 1 u, 2 U2 1 U,11 U2 1 U, 1 U2 1 1 10 u1 3 U2 11 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 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 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ElB Injury and for Tow Due To Crash YR 202512025-00079728 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1 ® ❑ RELATED ®Y ❑N 12 16 2025 ❑AM ❑YES ®NO U1 S CLIFTON AVE Elgin02:24 _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m FT!MI N E S W CARR ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 1 (n ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ❑ FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑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) FRONr TOWED U1 Q Delgado.Ofelia. P. 0 3 / yr 13-UNDER CARRIAGE ©,I I�. FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U22 2 m F 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 _ ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF & i�B �i 4 COM VEH 0 Ea 1 0 ELGIN I N I L 60123 0 1 0 FIRST CONTACT 11 7_: __5 *lI Ves.See Sidebar U1 Z AZ14009 IL 2026 REAR TELEPHONE IL D 0 1 G6DA5E50C0137396 State Farm ❑v Igl N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same 1910851-SFP-13 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER > 73 Refused 0 Y ElN 2 0 p; DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑NIAV 0 i v ❑DV !1 9 9 4 BMW 320 2013 00-NONE O, . 12..-_, DUE TO CRASH 0 2 73 o 13-UNDER CARRIAGE 10� 2 FIRE ❑ ® U2 C c M 2 4SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 0 X 0 Y ❑N 0 UNK VEH. AT CRASH 99-UNKNOWN *Oistrac) n Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF ?Li B i.�., 4 COM VEH ❑ ® U1 W F„ FIRST CONTACT 11 _,__5 ••If Yes.See Sidebar C ELGIN IL 60123 0 1 0 FN85503 IL 2026 REAR 0 Si) M IL D 0 WBA3C3C5XDF982696 United Equitable ❑Y J N RDEF M EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 = Same ILU020733 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused 0 Y°ND O 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 N 1 ® 11 1 12,16 l2025 02 51 ®AM in a Work Zone? ®N DIRP co 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 C) Si , 2 28 14 ) ! 0 PM 0 Construction * R 3 0 $I CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 o1 ® 11 1 ARREST NAME Delgado.Ofelia. P. 11-601-Ax S1529-000571 , ! El PM SLMT o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility 25 r 2 ARREST NAME AM 7 1 1 ❑❑PM 0 Unknown work zone type U1 El OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 1529-Audi red.Jonathan 601 269-Mendiola 01 +06,2026 09 00 D PM Workerspresen,7 ®N U2 25 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-- --; ; } } } i- -, , ; ; , ; ( INDICATE NORTH combination):or -1 p1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } ' , } (example:shuttle or charter bus):or X 3. Is L L.-_------ 1 i. <--_- -___� J transporting employened to es Inhecourse 5 or fewer o their eers mplod yment example:employeener X } } } transporter-usually a van type vehicle or passenger car):or 1:0 I- <.__-a-_-_-I , l• I• I- <--_-a____� . , , , 4. Is used ordesi nated to trans rt between 9 and 15 passengers,including C} } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or 0 L L-. ._i_. -_.: L L L L.__-.�_ j l. 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 CARRIER NAME Z i. ADDRESS 0 , n CITY/STATE/ZIP MOTOR CARR.ID 0 Interstate 0 Intrastate 0 ❑ Not in Comm./Govt. ❑ Not in Comm./Other 0 USDOT NO. ILCC NO. m XI Source of above z IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No = 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 Gray Gray 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