HomeMy WebLinkAbout2025-00080562 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
10110111110111101000, �
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X�0:79810
u, 1 U21 2 4 1 U1 2 U2 1 U, 1 1_12 1 U, 1 U2 1 1 15 U1 1 U2 1 *P 0119*
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 El$501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 2025I 2025-00080562 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
® ❑ RELATED ®Y ❑N 12 21 2025 ❑AM ❑YES ®NO U1 -<
HILL AVE Elgin 03:00
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION ITI
FT!MI N E S W SUMMIT ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
lgi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL ❑EWES ❑uuv ❑!CV 0 CM DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
T�TOWED U1 0
mo
Mora.
yr 13-UNDER CARRIAGE . FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL O4-TOTAL(ALL) 10 2
DISTRACTED THER ® ❑ U2 O 1T1
F 2 SYSTM 8 ❑Y ONE DUNK VEH. O AT CRASH 0 15-99-UUNKNOWN 9 16•TOP 3 *Distraction Value 5 ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�a a COM VEH 0 Ea 1 00
~ ELGIN I L 60120 0 1 0 FIRST CONTACT 12 7_: __S *IIYes.See Sidebar U1
ZFM11244 IL 2026 E
TELEPHONE
IL D 19U UA66244A062853 Falcon ❑Y ®N U2 m
B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
co
Moyado.Gabriel 0100138728-2 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 eu
m x DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0
/1 9 9 0 Chrysler Sebring 2008 00-NONE 'o,��12 ;,-2 UE FIREo CRASH D U2 2 C
0 13-UNDER CARRIAGE II
c
F 2 8 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16•TOPO3 * X
❑Y i N ElUNK VEH. AT CRASH 99-UNKNOWN 0i$tracJDn Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s
FIRST CONTACT 4 7-'- 1 6 I• (_S 4 COM(ryesV.EH See Sidebar❑ El
CO
•
= ELGIN IL 60123 B 1 0 FM22267 IL 2026AR
IL D 1C3LC56R88N270216 State Farm ❑Y 123 N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire Same 2223120-SFP-13 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Provena St.Joseph 0 Y°ND
0 N U1 =
(UNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
2 3 11 / 2 8 0 1 0
m
/ / #OCCS D
71
/ / U1 1 D
/ / 2 O
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur El U2 Z
N 1 ® 11 4 12,21 /2025 03 00 ®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
Eri 2 0 1 6 2 23 12,21 /2025 03 00 PM
® • ❑Construction >E
R O 0 gi CITATIONS ISSUED El PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
3 ❑AM ❑Maintenance U2
o ® 11 4 ARREST NAME Mora. Melanie 11-601-Ax 487000651 12/21 /2025 03 02 Igi pM• • El Utility SLMT
lgi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM
o TiN 2 0 36 6 ARREST NAME Mora. Melanie 11-904-B 487000650 12/21 /2025 03 16 ®PM El Unknown work zone type U1 35
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 30
487-Heal. Kayla 201 269-Mendiola 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.
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 -<
` ` -'- ' r INDICATE NORTH combination):or .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
0 _ } (example:shuttle or charter bus):or
tK'
3. Is des ned to car 15 or fewer L L.___A-_ y } } } transportig em to ees In the coursee o their emplo operated by a c:emplt gamer O
transporterg-usually a van type vehicle or passenger cart(or(example:employeeco
• W/B?Sammlt9S[ C
4. Isusedordesi natedtotrans rtbeen9and15 ge ng for direct compensation(examp::Marge van used for specific purpose):orI rer,- t } } t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires_ mmIMS1placarding(example:placards will be displayed on the vehicle). m
CARRIER NAME Z
Unh 1 • - i. i. __ ADDRESS D
rA
X1117Ave
Not To Scale I CITY/STATE/ZIP n
MOTOR CARR.ID 0 Interstate 0 Intrastate
I r ❑ Not in Comm./Govt. 0 Not in Comm./Other
; _Y_ __.; USDOT NO. ILCC NO. m
XI
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 M
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
to
LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 0 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Gray Blue
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
Arties/Impound Lot Garage . 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