HomeMy WebLinkAbout2025-00080235 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004076092*
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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 El$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
❑AMENDED YR 2025I 2025-OOOHOZ35 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
N LIBERTY ST Elgin01:37
® ❑ RELATED ®Y 0 N 12 19 2025 12,— ❑YES ®NO U1 -<
g PRIVATE mo !day/yr ®PM FLOW CONDITION In
FT!MI N E S W SUMMIT ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 3 Cl)
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑uuv ❑ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 5 n
FOR DAMAGEDAREA(S) FRO fir TOWED U1 Q
JIMENEZ LOZANO,VICTOR.G. 1 1 /
yr 13-UNDER CARRIAGE 101 •�. FIRE 0
NI
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U22 5 M
M 2 6 SYTM❑Y ®S NE❑UNK VEH. 0 AT CRASH 0 99-UNK 15- NOWN THER9 16•TOP® *Distraction Value ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s_iL B if.4 COM VEH 0 Ei 1 0
~ ELGIN I L 60123 0 1 0 FIRST CONTACT 3 7_; _-5 *II Yes.See Sidebar U1
Z EN93856 IL 2026 REAR
TELEPHONE
IL D 0 1 HGCV1 F3XNA088340 ALLSTATE ❑Y ®N U2 I''I
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 QUINTANILLA VIDAL, MIRLEY,S. 979546272 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 XI
��, g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES O New ❑nKV 0 DV
/1 9 8 2 Mercedes-Bennprinter 2018 oo-NONE 11_j Qj,-_, DUE TO CRASH rg ❑ 2 x)
o 13-UNDER CARRIAGE 10) ) 2 FIRE 0 ® U2 C
M 2 5 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y ®N DUNK VEH. AT CRASH 99-UNKNOWN •Oistracton Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-iI�1:,-4 COM VEH ❑ ® U1 co
CONTACT 12 7 _, .5 •If Yes.See Sidebar
H ELGINZ IL 60123 B 1 0 455260D IL 2026
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M
IL D 0 WD3PF1 CDOJ P621601 SAFECO ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
Elgin Fire 99 9 LAI, PAU,A. Z5425017 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
u1 =
(UNIT) (SEAT) IDOBI (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 3 11 / M 2 6 0 1 0
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/ / #OCCS D
71
/ / UI 2 D
/ / 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 4 12,19 ,2025 01 37 ®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 C)
v 2 2 28 12,19 ,2025 01 37 ®PM 0 Construction >E
R 3 0 xi CITATIONS ISSUED ElPENDING SECTION CITATION NO. EMS ARRIVED TIME J
z J ❑AM ❑Maintenance U2
-a, ARREST NAME JIMENEZ LOZANO.VICTOR.G. 11-901-A 374001358 12,19,2025 01 46 ®CITATIONS ISSUED PENDING PM SLMT
1 ® 11 4 ❑ Utility o u SECTION CITATION NO. ROAD CLEARANCE TIME 0
r 2 El ARREST NAME 12/19 ,2025 02 10 0 PM 0 Unknown work zone type 0 AM
U1 30
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 0 AM Workers present? ❑Y 30
374-Rizzu-o, Michael 201 11 , 12 ,26 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.
N.7LIBERTY?STREET
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 -<
c ` -' -' • INDICATE NORTH combination):or —I
UNIT 1 y BY ARROW 2 Is used or designed to transport more than 15 C
i
- } (example:shuttle or charter bus):n or passengers including the driver
i f f T
p.
' I ._.' sUNMmrsTREEr ,+
3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
- - - - /—1 — — — - } } } transporting employees In the course of their employment(example:employee X
.,ti_ transporter-usually a van type vehicle or passenger car):or w
1 ff., j, r } } } 4. Is used or designated to transport between 9 and 15 passengers,including the driver. fn
• r for direct compensation(example:large van used for specific purpose):or O
L i t i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
— — —_ _ — —_ _ placarding(example:placards will be displayed on the vehicle). XI
—1
CARRIER NAME Z
ADDRESS
w
n
Not To Scale CITY/STATE/ZIPg
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
I I '
,....Y_ ._ USDOT NO. ILCC NO. m
XI
Source of above z
. ❑ Yes 0 No 0 Unknown g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash? A
0 Yes No ❑ Unknown C
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 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 White
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE