HomeMy WebLinkAbout2025-00081623 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
IIIIII II 1111 101lIll01000
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV *X004097060*
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INVESTIGATING AGENCY DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ElOVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 2025I 2025-00081623 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED ❑Y ®N 12 28 2025 DAM ❑YES ®NO U1
S LIBERTY ST Elgin 07:15
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION IT1
EI50 /MI N E S W South Chicago St COUNTY PROPERTY ❑Y ® N DOORING ❑Y #OF MOTOR ❑SLOW 1 (n
® g Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ® STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ❑ FREE FLOW # LNS 0
tg:DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑KIN ❑!CV ❑DJ DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 0FOR DAMAGED AREA(S) FRONT TOWED U1 0
Arizmendi Giba Jor e. L. 0 5 /
yr 13-UNDER CARRIAGE �a:) 2 , 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0U2 3 <<T1
M 2 4 ❑Y ®Nn 15-OTHER
SYSTEM
❑UNK VEH. AT CRASHD 99-UNKNOWN 9 76•TOP 3 *Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 7_iL a I,.4 COM VEH 0 )gJ 1 O
I= 60110 0 1 0 FIRST CONTACT 12 7_; _5 *II Yes.See Sidebar
U1
z ED50421 IL 2026
TELEPHONE
IL D 0 2HKRS4H76PH434818 Statefarm ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
Palacio. Nisha 3516436SFP13 2 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 XI
Eg DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES O Nuv 0 icv ❑Dv
/1 9 yr 5 Land Rover LR4 2012 00-NONE ,�_"i 12'"_, DUE TO CRASH ❑ (� 2
0 13-UNDER CARRIAGE to l E FIRE ❑ ® U2 C
c
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP 3 X
❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 0
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 DX98308 IL 2026 iEAR 0
IL D 0 SALAK2D49CA598183 Kemper Insurance ❑Y IZI N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Duran Mujica.Zelita 12AU001354833 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOBi (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME))(ADDRESS))(TELEPHONE) (EMS) (HOSPITAL)
1 3 11 /
' D
/ / 3 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
u 1 El 11 1 12/28 /2025 07 15 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
o"
2 ❑ 28 99 / / 0 PM• 0 Construction *
Z 3 0 Igi CITATIONS ISSUED El PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
-a, ARREST NAME Arizmendi Garibay.Jorge. L. 11-601 748071 / / El PM SLMT
1 ® 1 1 1 ISI CITATIONS ISSUED ❑PENDING Utility
o N SECTION CITATION NO. ROAD CLEARANCE TIME AM• 0
t 2 El ARREST NAME Arizmendi Garibay.Jorge. L. 6-303-A 748070 12/28 /2025 08 52 ®PM El Unknown work zone type U1 35
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 35
1500-Chew. Marie 301 269-Mendiola 01 /21 /2026 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
ADDITIONAL UNITS FORMS.
UM 1 I A CMV is defined as any motor vehicle used to transport passengers or property and: Z
OS
r -- r••--, N. 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
i- -----'-----4. I - INDICATE NORTH combination):or p3
x g transport passengers including the driver C
7 U BY ARROW 2 Is used or designed to tran ort more than 15
} z I } ,. (example:shuttle or charter bus):or C
Not To Scale O I unit 2 I 3. Is desgned to carry 15 or fewer passengers and operated by a contract carrier I
} } } transporting employees in the course of their employment(example:employee X
E7Chiwpo781 ` ' transporter-usually a van type vehicle or passenger car):or co
L L.___a__._� 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including N
} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or O
L L____a____. � i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
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placarding(example:placards will be displayed on the vehicle). ,Zmt
CARRIER NAME Z
ADDRESS 0
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate ❑ Intrastate
I I T I I ❑ Not in Comm./Gout. Not in Comm./Other
r ----- ------ 1 - USDOT NO. ILCC NO. m
XI
Source of above z
. xi
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
v
TRAILER WIDTH(S) 0-96" 97-102" >102' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Blue White
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 1 TOWED BY/TO.
Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE