HomeMy WebLinkAbout2025-00081158 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 0011110 1010111111111110111111111111111
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004112231
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY 0$500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑5501-$1.500 ®ON SCENE 7
VEHICLE/PROPERTY ®OVER$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and f or Tow Due To Crash YR 202512025-00081158 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 6 m3 LONGWOOD PL Elgin12:39
® ❑ RELATED 0 Y ®N 12 25 2025 ❑AM ❑YES El NO U1 -<
_ g PRIVATE mo /day/yr ®PM FLOW CONDITION MCOUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR ❑SLOW 1 fA
❑ FT!MI N E S W Kane 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 t] PARKED El DRIVERLESS 0 PED 0 PEDAL 0 EDUES 0 NW 0 ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 00 n
FOR DAMAGEDAREA(S) FROPtf TOWED U1 O
Reveron Chacon.An ie. M. 1 0 !
yr 11 12 -1 ❑
13-UNDERCARRIAGE 10 ` 2 FIRE 0 NI
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 !a U2 00 M
F 2 SYTM IN ENGAGETHER
3 ❑Y ❑SNE®UNK VEH. 9 AT CRASH 9 99-U15-UNKNOWN Ole•TOP 3 ,Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s,_iL B �i 4 COM VEH 0 Ea 1 0
~ ELGIN I N I L 60123 0 1 0 FIRST CONTACT 9 7 : __5 *Ir Yes.See Sidebar U1
Z AE48483 AZ 2026 REAR
TELEPHONE
IL D 1 FDXE4FS5CDA49137 State Farm ❑Y ®N U2 19 . m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Uhaul Co of Arizona 3526810SFP13 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
26 0
0 DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 iiuv 0 i v 0 Dv
yr 10;f 12 c, 2 FIRE ❑ ElU2 1 C
o 13-UNDER CARRIAGE
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN 9 ENGAGED 9 15-OTHER 9.1,6•TOP 3 0 ® SPDR n
❑Y ❑N ®UNK VEH. AT CRASH 99-UNKNOWN O *0istrac on Value 9 U1 0
POINT OF 8-.;, a
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR B ,t COM VEH ❑ ® CO
F,,, FIRST CONTACT .5 7-� —_�i.OS •(ryes,See Sidebar
FB68852 IL 2026 I 0 Si)
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
ZARFAEDN7H7540285 State Farm ❑Y ®N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
Ramirez Rodriguez. Luis.G. 2088991-SFP-13 BAG E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (D081 (SEX) {SAFT) (AIR) (INJ) (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
W 05 /
00 O
EV MOST EVNT LOS DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 18 5 co
12,25 l2025 12 39 ®PM AM in a Work Zone? ®N DIRP >
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 2
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
o"
2 0 18 18 ! ! ❑PM• 0 Construction *
R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 2
❑AM 0 Maintenance U2
o1 ® 11 5 ARREST NAME Reveron Chacon.Angie. M. 11-404-A 410000775 / ! El PM SLMT
o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' 0 Utility
AM
r 2 0 ARREST NAME / / ❑❑PM 0 Unknown work zone type U1 OO
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 00
410-DeLeon.Jessica 501 01 /20/2026 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----; combination):or —I
A r INDICATE NORTH p1
I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
N _ } (example:shuttle or charter bus):or
X
L A 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__. 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or 0
L :. _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D
#i.i »m, dtPt placarding(example:placards will be displayed on the vehicle). ,Zmt
�='
.... _ CARRIER NAME Z
ADDRESS 0
C)
CITY/STATE/ZIP g
Not To Scale MOTOR CARR.ID ❑ Interstate 0 Intrastate
I I , I ❑ Not in Comm./Govt. 0 Not in Comm./Other
-"--------1 - USDOT NO. ILCC NO. rn
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' m
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: 1 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE