HomeMy WebLinkAbout2025-00080292 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 1111 III 11 IIIIII UHI U
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY El OVER 51,500 El NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and for Tow Due To Crash YR 2025I 2025-00080292 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
N SPRING ST Elgin 05:57
® ❑ RELATED ®Y ❑N 12 19 2025 DAM ❑YES El NO U1 -<
_ _ g PRIVATE mo !day!yr ®PM FLOW CONDITION MFT!MI N E S W SUMMIT ST COUNTY PROPERTY :IN Y ® DOORING Ely #OF MOTOR 0 SLOW Cl)
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EDUCE 0 NW 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
FOR DAMAGEDAREA(S) FRONT TOWED U1 Q
Baires-Vanegas. Francis.G. 1 2 /
yr 11_, 12 _t ❑ VIE
13-UNDER CARRIAGE 10 i 2 FIRE 0 IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 Ea U2 rn
M 2 SY is-OTHER
4 ❑Y ®SNE❑UNK VEH. 0 AT CRASM IN H 0 99-UNKNOWN 9t6•TOP 3 `Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s_iL B 4 COM VEH 0 Ea 1 00
~ ELGIN IL 60120 0 1 0 FIRST CONTACT 00 7_; _5 *IIYes.See Sidebar Ut
Z EC62542 IL 2026 REAR
TELEPHONE
IL D 0 1J8FF47W58D513512 Unknown ❑Y ®N U2 r
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same Uknown 1 1—
"6 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Provena St.Joseph ❑Y El 2 0
0 DRIVER 0 PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES 0 row
yr 12 _ C
o 13-UNDER CARRIAGE 1U I c. 2 FIRE ❑ ❑ U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 ❑ El SPDR 0
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN POINT OF 8 4 `Distraction Value 0 -
-
EH
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT Y ='+:-5 CIO e1sVSee Sidebar❑ ❑ U1 C
CO
F` •
-- C
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O
❑Y ❑N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
BAC
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
RESPNDER❑YD❑N U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0
W 1 2 /
0
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 CO 43 2 12!19 l2025 05 57 ®AM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 10
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
;, 2 ❑ 36 1 17 99
t ! ! ❑PM• ❑Construction *
Z3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2
-a, ARREST NAME ! ! ❑PM '
o u 1 0 ❑CITATIONS ISSUED ❑PENDING UtilitySLMT
o N SECTION CITATION NO. ROAD CLEARANCE TIME El
t 2 El ARREST NAME 1 2!19 12025 06 25 ®PM El Unknown work zone type U1 0 AM
35
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y
2 3 ❑ ❑AM Workers present?
CI1500 Chew. Marie 102 391-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
ADDITIONAL UNITS FORMS.
r ----r••--, , I ^� ; 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 -
r__--; y, U ( combination):or —I
, P- I [.. INDICATE NORTH p3
dS BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
Not To Scale ` - (example:shuttle or charter bus):or 0
I- I- --I--•--; I transporting mployeened to slin the course passengers5 or fewer thir emplod yment example:employeener X
} } } }
transporter-usually a van type vehicle or passenger car):or ED
L •-----}----; t rilk', - } i. } •4. Is used or designated to transport between 9 and 15 passengers,including the driver. C
gntt for direct compensation(example:large van used for specific purpose):or O
L L____a____.
—
I — — — _ i � t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
m
placarding(example:placards will be displayed on the vehicle). ;p
Summk?St illi I i I / - -- CARRIER NAME Z
ADDRESS
Unit 1 >
1,+'( � CITY/STATE/ZIP 0
0
r : Ij�j, i. 4. MOTOR CARR.ID El Interstate El Intrastate
Unit 1 ❑ Not in Comm./Govt. ❑ Not in Comm./Other 00
USDOT NO. ILCC NO. C
m
Xl
Source of above z
IDOT PERMIT NO. WIDELOAD-; ❑Yes 0 No =
TRAILER VIN 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U_COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Beige
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 0 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U_DUE ETOO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO DUE T VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE