HomeMy WebLinkAbout2025-00078517 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 0110 1111,N�� I 10100
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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 ❑g501-g1,500 ®ON SCENE 1
VEHICLE/PROPERTY ElOVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
0 AMENDED YR 2025I 2025-00078517 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 71
N STATE ST Elgin 05:25
® ❑ RELATED ❑Y ®N 12 10 2025 ®AM ❑YES IX]NO U1 -<
PRIVATE mo !day!yr ❑PM FLOW CONDITION m
5 !MI N E COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
0 VY West Hi ghland AYe Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS O
0 DRIVER ❑ PARKED ❑DRIVERLESS Eg PED 0 PEDAL 0 EWES 0 NIAV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
FOR DAMAGEDAREA(S)
OBILEYE.AHMED. L. mo !1 9 5 2 FR4T TOWED U1 Q
NAME(LAST,FIRST,M) 00-NONE
13-UNDER CARRIAGE „ • 12! , DUE TO CRASH 0 ENE
101 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U22 2 m
M SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 _
❑Y El N ❑UNK VEH. AT CRASH 99-UNKNOWN 6 l 4 `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF L 6 ii COM VEH 0 Ea 1
0
ZELGIN IL 60123 K FIRST CONTACT 99 r _s *If Yes.SeeSideDar u1
TELEPHONE
IL ❑Y ❑N U2 I'
IL'in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
1 47 1 2 m
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
.5 El> E PO D N XI
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g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑NAV ❑NOV ❑DV CIRCLE NUMBER(S) U1
!2 0 0 2 Nissan Rogue 2016 00-NONE 0. 12.._, DUE TO CRASH rg ❑ 2 x
0 13-UNDER CARRIAGE o 2 FIRE ❑ ® U2 C
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN •Oistracton Value 6
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s_i�!-4 COM VEH ❑ ® U1 CO
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FIRST CONTACT 11 Y._�_, _s •If Yes.See Sidebar C
ELGIN IL 60123 0 1 Z874113 IL 2026 REAR
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IL C 5N1AT2MN5GC753721 STATE FARM INS ❑Y ®N RDEF XJ
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire 1 47 1 SIFUENTES VAZQUEZ.GUADALUPE 1701106-SFP-13 BAC
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HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
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(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1{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 ® 12 1 12,10 /2025 06 10 ®❑PM in a Work Zone? ®N DIRP D
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1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES Check one below:
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1
v 2 18 18 12 r 10 ,2025 06 10 ❑PM 0 Construction *
Z 3 0 ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
®AM ❑Maintenance U2
- N ®a ARREST NAME 12!10,2025 06 15 ❑pM '
1 12 1 ElUtility
0 ISSUED ❑PENDING SLMT
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SECTION CITATION NO. ROAD CLEARANCE TIME t 2 ElARREST NAME 12/10 12025 10 13 MA PMM ElUnknown work zone type U, 3U
n T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 - ❑AM Workers present? ❑Y 30
359 Williartson. Linda 701 , , ❑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-_--; } INDICATE NORTH combination):or —I
No14DRAwN,tioreCALe P1
E�"- BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
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` A I G 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier O
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employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
L L.___a__ ---- - 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including C——— — - } for direct compensation(example:large van used for specificpurpose):or [he driver,
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L 5. Is any vehicle used to transport hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). XI
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uwi Uter MEW. CARRIER NAME Z
arrarerer I rnsra, sr __ ADDRESS O
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CITY/STATE/ZIP 0
I - i. i. i. i. 4. MOTOR CARR.ID ❑ Interstate ❑ Intrastate
0
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
-"-------1 - USDOT NO. ILCC NO. m
XI
Source of above z
. 0 Yes II No ❑ Unknown A
Was a driver/vehicle Examination Report Form completed? r
HAZMAT ❑Yes 0 No ❑Unknown Out of Service ❑Yes ❑No :
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 VIM 1 m
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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
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 9 TOWED BY/TO.
SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE