HomeMy WebLinkAbout2025-00081948 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 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$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
El AMENDED
YR 2025I 2025-00081948 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 mCONGDON AVE El02:30
® ❑ RELATED ®Y 0 N 12 30 2025 ❑AM ❑YES ®NO U1
_ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION m
FT l MI N E S W DUNCAN AVE COUNTY PROPERTY ❑Y ® N DOORING ICIy #OF MOTOR 0 SLOW 1 0)❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IN N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 NOV 0 lacv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
0 9 !
yr . Q
13-UNDER CARRIAGE FIRE ❑ lE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED ❑ 0 U2 2 m
F 2 5 ❑Y ®SNEM❑ n 15-OTHER
UNK VEH. AT CRASHIN n ENGAGED 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6,_i� 6 �i COM VEH 0 j$J 1 0
~ 60110 0 1 0 FIRST CONTACT 1 7 . -_5 *lives.See Sidebar U1
ZDB89393 IL 2026 iivui
TELEPHONE
IL D 0 5J8TB18518A012324 American Family Insurance ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
GRIMALDO. DONJUAN. M. 1702-8375-07 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER
2 eu
m g DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑ uv ❑NOV ❑Dv
!1 9 5 0 Chevrolet Cavalier 1999 00-NONE ,�_"i Qj O DUE TO CRASH ❑ 2
13-UNDER CARRIAGE I FIRE El El U2
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,19-TOP 3 X
❑Y ®N El UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 iI 6 i�:- 4 COM VEH ❑ ® U1 CO
FIRST CONTACT 12 Y .5 •IfYes.See Sidebar
= ELGIN IL 60120 0 1 0 1567079 IL 2026 I 0
IL D 0 1 G 1 JC1246X7211764 Allstate ❑Y 123 N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Same 102 210 860 BAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND
❑N 9 U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 1 12,30 l2025 02 47 ®PM 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
2 23 28 I / ❑PM ❑Construction *
O) 1 4
R 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM ❑Maintenance U2
-a, ARREST NAME GRIMALDO AVALOS.Ashley. R. 11-1204-B 476000425 / ! ❑PM SLMT
o U1 ® 11 1 CITATIONS ISSUED 0 PENDING Utility
o NSECTION CITATION NO. ROAD CLEARANCE TIME AM• , ❑
t 2 ❑ ARREST NAME Rios.Antonio 6-101 476000426 12130 ,2025 03 39 ®PM ❑Unknown work zone type U1 30
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
476-Ramos.Clarissa 102 337-Thompson 01 ,20/2026 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.
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 -<
c ` -' -' r INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} L } rt-
... !' !- I. (example:shuttle or charter bus):or
3. Is< <---- -•-"; transporting employeened to s 5 or fewer Inthe course passengers
their emand ployment operated
xample:employee
transporter
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transporter-usually a van type vehicle or passenger car):or 03
L }-----}----; 41i ♦— I. } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver, w
i,.%, for direct compensation(example:large van used for specific purpose):or O
• OagdorflMw •D
L i.____a____. •. t i. i i. t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
.0 placarding(example:placards will be displayed on the vehicle). ;p
i ii•
—il i; - CARRIER NAME Z
ADDRESS 0
w
Not To Scale CITY/STATE/ZIP n
MOTOR CARR.ID 0 Interstate 0 Intrastate
1 r ❑ Not in Comm./Govt. 0 Not in Comm./Other
; _Y____1 - USDOT NO. ILCC NO. m
XI
Source of above z
. 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 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Silver Blue
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 2 TOWED BY/TO.
Other/Owners Residence . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® Redmons/Owners Residence VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE