HomeMy WebLinkAbout2025-00000586 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 15
VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT)
El AMENDED ElB Injury and for Tow Due To Crash YR 202512025-00000586 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 m
® ❑ RELATED ®Y 0 N 01 03 2025 ❑AM ❑YES ®NO U1 -<
W CHICAGO ST Elgin02:52
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W N CRYSTAL AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 3 (n
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EDUCE 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
0 4 !
yr 13-UNDER CARRIAGE ) Z : Z FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 0 m
F 2 SY4 ❑Y ®SNEM❑UNK VEH. 0 AT CRASH 0 IN ENGAGED15-OTHER
99-UNKNOWN 9 76•TOP 3 *Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ iI 6 4 COM VEH 0 j$J 1 0
~ ELGIN I N I L 60123 0 1 0 FIRST CONTACT 12 7 ;{ _5 *II Yes.See Sidebar U1
Z EW45833 IL 2025 REAR
TELEPHONE
IL D 0 1 G KER23D09J 105266 State Farm ❑Y Igl N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 3338286-SFP-13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused El El 2 c
N DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑ uv 0 NOV ❑DV CIRCLE NUMBER(S) U1
!1 9 yf 6 Dodge Caravan(inc Grand)2016 Do-NONE i1_"j t2..-_, DUE TO CRASH ❑ 2 x
o 13-UNDER CARRIAGE 1 FIRE ❑ ® U2
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOPO3 * X
❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN Distraction Value 9 0
POINT OF s i1 �I COM VEH ❑ ® U1 W
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR A 5 r,_
FIRST CONTACT 2 7�. -5 •If Yes.See Sidebar
= Round Lake IL 60073 0 1 0 EG27118 IL 2025 I 0
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IL D 0 2C4RDG BG6G R122845 State Farm ❑Y ®N RDEF .73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 2679526-SFP-13 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 El 11 4 11 ,12 !25 02 53 ®pM in a Work Zone? NJ DIRP D
1 t PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 5 n
0 T
2 ❑ 2 18 ! / 0 PM• El Construction *
7
Z 3 0 lyg CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2
oEl 11 4 ARREST NAME Saythany. Linda 11-901 499000743 / ! El PM SLMT
o N 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility
r 2ARRESTNAME AM
T ❑PM 0 work zone type U1
El 1 1 ❑
2 2 3 ❑ OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
499-Dirck.Cameron 601 334-Fries 11 , 81 ,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
ADDITIONAL UNITS FORMS.
A CMV is defined asmotor vehicle used to transportand:
r ----,5-••--, ; any passengers or property
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1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
• i.-- -i-- --; } } } r -, , ; ; , ; ( INDICATE NORTH combination):or —I
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BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ' i 1 , } (example:shuttle or charter bus):or
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3. Is
. L.___A_. 1 ..._.... J transporting edmployeeslIn5 hecourseeo theire rsmployment exam pal
e:employeener 73} } }
transporter-usually a van type vehicle or passenger car):or co
< <.__-a-_-_, , 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 L___-a____.: L L L ...._-..i.____� l. i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). XI
--I
CARRIER NAME Z
ADDRESS 0
T.
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other O
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 g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash?
❑ Yes II No ElUnknown A
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
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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. Z
White Blue
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 2 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE