HomeMy WebLinkAbout2025-00080886 ILLINOIS TRAFFIC CRASH REPORT sheet 1 Of 2 Sheets 01111101111
0110 1111,1fll0ll0lllI 100
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X�0:9822`
u, 1 U21 1 1 1 U1 7 U2 1 u, 1 1_12 1 u, 1 U2 1 3 11 u1 1 U2 7 *P 0 1 1 9*
INVESTIGATING AGENCY DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S El5501-51.500 ®ON SCENE 1
VEHICLE/PROPERTY ElOVER$1,500 El NOT ON SCENE(DESK REPORT) 0 B Injury and/or Tow Due To Crash
0 AMENDED YR 2025I 2025-00080886 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I
1077 SUMMIT ST EIIn04:47
® ❑ RELATED ❑Y ®N 12 23 2025 12,— ❑YES ®NO U1 -<
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 u)
❑ FT/MI NESW Cook HIT&RUN ❑Y ® N WITH VEHICLES INVLD ® STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES 0 uuv 0!Cy 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
FOR DAMAGED AREA(S) FR4T TOWED U1 0
NAME(LAST,FIRST,M) Garcia.Griselda mo Nissan Rogue 2004 00-NONE 11;. OI"_, DUE TOCRASH ❑
EN
13-UNDER CARRIAGE 10 ' 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14--TOTAL(ALL) DISTRACTED 0 0U2 4 <<Tl
F 2 4 ❑Y ®SYSNEM❑UNK VINEH. O AET CRASHD 0 99-UUNKNOWN THER 9 76.70P 3 ,Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s ;iI B 4 COM VEH 0 j$J 1 0
~ ELGIN I L 60123 0 1 0 FIRST CONTACT 12 7_;1 _5 *II Yes.See Sidebar U1
Z FE63640 IL 2025 REAR
TELEPHONE
IL B 0 JN8AS5MT2EW600253 American Alliance Insuran ❑Y Igl N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same I LAA-1102645 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y ❑ N 2 eu
m x DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑iiuv 0 IrDv 0 Dv
'1 9 6 4 Hyundai Santa Fe 2017 00-NONE +i_"' ,z'-_, DUE TO CRASH ❑ (� 2
0 yr 13-UNDER CARRIAGE 101 l 2 FIRE 0 ® U2 C
c
M 2 4 SYSTEM IN 0 ENGAGED 0 ®-OTHER 9 16.TOP 3 9 0 X
❑Y ®N DUNK VEH. AT CRASH 99-UNKNOWN *Oistrac Dn Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S iI S I,,_4 COM VEH ❑ ® Ut CO
FIRST CONTACT 6 Y__{_O ._5 •If Yes,See Sidebar
= ELGIN IL 60120 0 1 0 EC34502 IL 2025 IAR
IL D 0 SXYZTDLB9HG403242 Progressive Insurance ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
99 9 Same 866181775 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused 0 Y°ND
O N ui =
(UNIT) (SEAT) (DM (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME(1(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
1 6 09 /
:A
/ / UI 02 ' D
/ / 2 0
EV MOST EVNT LOC, DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 1 12,23 ,2025 04 48 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
v 2 ❑ 28 03 12,23 ,2025 04 47 ®PM ❑Construction >F
R 1 3 0 ]$I CITATIONS ISSUED ElPENDING SECTION CITATION NO. EMS ARRIVE° TIME 7
z J ❑AM ❑Maintenance U2
a ® 11 1 ARREST NAME Garcia,Griselda 11-601 1562000060 12,23 l2025 04 56 Igi pM SLMT
o N I]CITATIONS ISSUED TIME PENDING SECTION CITATION NO. ROAD CLEARANCE • 0 Utility
30
t 2ARRESTNAMEAM
7 El / / ❑❑pM 0 Unknown work zone type U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 3O
1562-Amador,Aidan 201 269-Mendiola 11 , 3/ ,025 09 00 ❑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
A ADDITIONAL UNITS FORMS.
r ----r••--, , N - ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
Not To Scale I 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
` ` --I -' �.e.. r INDICATE NORTH combination):or .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ } (example:shuttle or charter bus):or
X
— 3. Is designed to carry15 or fewer passengers and operated a contract carrier 0
I- }.---A----I "; ®i - 7 } } } transportingemployees In the course of their employment
pbyment(example:employee 73
transporter-usually a van type vehicle or passenger car):or w
L 4. Is used or designated to transport between 9 and 15 passengers,includingN}-----}----; - } } } g po passen rs,includi the driver,
for direct compensation(example:large van used for specific purpose):or O
L i t i 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 0
w
C)
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate ❑ Intrastate
,omaw.wna ❑ Not in Comm./Govt. ❑ Not in Comm./Other 00
--- --1 - USDOT NO. ILCC NO. C
m
XI
Source of above z
. —I
Were HAZMAT placards on vehicle? 0 Yes 0 No =
If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. Xl
Xl
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
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
Black Blue
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE