HomeMy WebLinkAbout2025-00079948 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets _ 01111101111 10110 ll 1111101111 1 11111111 II
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004076144*
u, 9 U2 1 1 1 U, 1 U2 U199 1_12 U,99 U2 1 9 9 U1 17 U221 *P 0119*
INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 7
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00079948 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m
809 ST CHARLES ST EIIn01:45
® ❑ RELATED ❑Y ®N 12 17 2025 DAM ❑YES El NO U1
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR IR SLOW 3 Cl)
❑ FT/MI NESW Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Q83 DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0 Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C)
/ ! FOR DAMAGEDAREA(S) I330P,r TOWED U1 Q
Unknown Unknown Unknown 00-NONE „ 12 , DUE TOCRASH ❑ EN
NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 10 IE
1 !�. 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 0 m
SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3
9 3 ❑Y ❑N ❑UNK VEH. AT CRASH ®-UNKNOWN `Distraction Value 9 ALGN 2
$ 4 COM VEH 0 j$J
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _i[s !i2 C)
~ 0 9 FIRST CONTACT 99 7_; _5 *II Yes.See Sidebar U1
REAR
2 Z ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1)
Unknown ❑Y ❑N U2 I-
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same Unknown 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
r D Y°N0 N
m ❑ DRIVER N. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 iiuv 0 i v 0 DV
yr Honda Odyssey 2023 00-NONE 1("j 12..-_, DUE TO CRASH ❑ 2 77
o 13-UNDER CARRIAGE 10'I c. 2 FIRE ❑ El U2 C
Ti SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ ® SPDR C)
0 0 16
NJ
IN ENGAGED 15-OTHER 9. -TOP 3 9 X
a 0 Y N 0 UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value
POINT OF 8 4 ut
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6 1�'`_ COM VEH ❑ ® CO
F,,, FIRST CONTACT 7 O7 __, _s •If Yes.See Sidebar
ED82920 IL 2026 REAR 9 N
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
5FNRL6H64PB069599 StateFarm ❑Y ®N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
99 9 Navarro Mojica. Maria.X. 1004259SFP13 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 18 5 12,17 l2025 05 13 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 ❑ 18 18
N 3 0 0 CITATIONS ISSUED 0 PENDING / / 0 PM• ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM 0 Maintenance U2
z
—a, ARREST NAME / / 0 PM
o N I ® 11 5 •
0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utili 15
ty
SLMT
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 15
1530-Soto.Oscar 401 391-Jacobucci 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
St?Charles?St ADDITIONAL UNITS FORMS.
. -- 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 -<
i- -----------; Not To Scale 1 !' INDICATE NORTH combination):or -I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
t N r r r (example:shuttle or charter bus):or
I
I- L.___A.._.� MI`, 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier O
} } } transporting 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 y} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or O
L i t i i ._ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D
placarding(example:placards will be displayed on the vehicle). XI
- —I
i I I - _ CARRIER NAME Z
1 ADDRESS
0
CITY/STATE/ZIP g
80g?Jt
MOTOR CARR.ID El Interstate El Intrastate
-
I I I Charles?St ❑ Not in Comm./Govt. Not in Comm./Other 0
-"-------1 - USDOT NO. ILCC NO. rn
Source of above z
. • m
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 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
co
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE 0 NOT DISABLING DAMAGE DAMAGE EXTENT 9 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE