HomeMy WebLinkAbout2025-00080473 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 4 Sheets 01111101111
I0110
II II IIIII.IIIIIIIIII
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XO.,IIII9PP35
u, 9 U21 3 4 1 U1 2 U2 1 u,99 u2 1 u,99 U2 1 5 10 u, 3 U2 1 *P 0119
INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT) (8:1B Injury and/or Tow Due To Crash
El AMENDED
YR 202512025-00080473 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m
N GIFFORD ST Elgin 10:11
® ❑ RELATED ®Y 0 N 12 20 2025 ❑AM ❑YES ®NO U1 -<
_ _ g PRIVATE mo !day!yr ®PM FLOW CONDITION Ill
FT!MI N E S W E CH ICAGO ST COUNTY PROPERTY El ® N DOORING Ely #OF MOTOR ❑SLOW 15 u)
❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD ❑ STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
/ / FOR DAMAGEDAREA(S) FROPtf TOWED U1 0
Unknown.O. Ford EcoSport 2019 00-NONE 1 t2 , OUETOCRASH ® ❑
NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 101 •�. 2 FIRE ❑ al
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 0 M
9 8 SYSTEM IN O ENGAGED 0 15-OTHER 916.70P�3 _
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s ij B �I COIN VEH 0 Ea 1 0
I- 0 9 0 FIRST CONTACT 4 7_: -0 •If Yes.See Sidebar U1 0
Z FL54391 IL 2026 REAR
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 2 lii
MAJ3S2GE8KC266748 UNKNOWN ❑Y ❑N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Santiago Puebla.Cesar.G. UNKNOWN 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
.5RESPONDER ( G0)
W g DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 RIU 0 NOV 0 Dv CIRCLE NUMBER(S) U1
!1 9 6 8 Buick Encore 2013 00-NONE O, ' Q1.O DUE TO CRASH 0 ❑ 2 73
0 13-UNDER CARRIAGE FIRE 0 ® U2 C
Ti
F 2 8 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s-i 0.1: COM VEH ❑ ® U1 CO
FIRST CONTACT 12 Y _, .5 •(ryes,See Sidebar
H ELGIN Z IL 60123 0 1 0 EF42205 IL 2026 0
M
IL D KL4CJGSBODB057773 State Farm ❑Y ®N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 13PPP6281 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
2 3 12 /
DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 1 City of Elgin.City.o. SIE telephone pole damage 12,20 /2025 10 11 ®PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 60
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 ❑ 380 COPPER SPRINGS LN ELGIN IL 60124 2 99 , , PM
0 • ❑Construction >F
Z 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM 0 Maintenance U2
-a, ARREST NAME / / ❑PM '
oN ❑ 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT
r 2 ® 20 3 ARREST NAMEAM
7 1 / ❑❑PM 0 Unknown work zone type 30
U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ID1517-Le Cates. Brittany 301 269-Mendiola , / ❑❑PM Workers present? ®N U2 30
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
r A p)
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
---{nacrrFrnorerva.cwl N _ } (example:shuttle or charter bus):or n
X
}
A I 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I 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____.l 1 4. Is used ordesi natedtotrans rtbetween9and 15 passengers,including w
} } for direct com nation exam I lar a van used for s �cifice ur o ):or the driver,
Pe ( P 9 Pe P Pose):or
L L.._-a-___.I — =A a— m'a 4,rI' R _ - i. < . L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
gm— placarding(example:placards will be displayed on the vehicle).
L cnia 1 II\ - ,e CARRIER NAME Z
ADDRESS
Not To Scale \ (s'�`fnao s"Evc N)# >
co
CITY /ZIP 0
MOTOR OR CA
CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
-"-------1 - USDOT NO. ILCC NO. m
XI
Source of above z
. Form Number
m
Xl
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
a
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 Black
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT' 2 TOWED BY/TO.
Arties/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE