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HomeMy WebLinkAbout2025-00001741 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 101101100 Oh DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X40a689/12 u, 1 U21 1 1 1 U1 2 U2 1 u, 1 1_12 1 1.11 1 U2 1 5 15 u1 1 u2 1 *P 0119* 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 ®5501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash El AMENDED YR 2025I 2025-00001741 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 mNESLER RD Elgin06:06 ® ❑ RELATED ®Y 0 N 01 08 2025 ❑AM ❑YES El NO U1 g PRIVATE mo /day/yr ®PM FLOW CONDITION Ill FT!MI N E S W GANSETT PKWY COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR El SLOW 2 Cl) ❑ 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 ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV ❑ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0 FOR DAMAGEDAREA(S) FROM I� Obao. Everlyne. M. 1 0 / yr 13-UNDER CARRIAGE I :: ©, FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 O 171 F 2 SYTM IN ENGAGE15-OTHER 4 ❑Y ®SNE DUNK VEH. O AT CRASHD O 99-UNKNOWN 9 16•TOP 3 `Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S, i�6 �i 4 COM VEH 0 Ea 1 0 ~ DEKALB IL 60115 0 1 FIRST CONTACT 1 7 ; __5 *lIVes.SeeSidebar U1 Z DX18716 IL 2025 REAR TELEPHONE IL D 0 5 N 1 AZ2AS5 LN 159427 State Farm ❑v Il N U2 I— in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same 0179038SFP13 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER > Refused ❑Y El 2 0 N DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑lily 0 i v ❑Dv !1 9 yr 9 Dodge Ram 1500(pickup) 2024 00-NONE .6! 112 c, 2 DUE TO CRASH 0 ® U2 14 C o 13-UNDER CARRIAGE c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracl n Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S-it 6 1:,-4 COM VEH ❑ ® U1 CO FIRST CONTACT 10 7�_, .5 •(ryes,See Sidebar n ELGIN D IL 60124 0 1 3769737B IL 2025 IL D 0 1 C6SRFMT1 RN 149238 Country Financial ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X 99 9 GTS ELECTRIC INC— AB9161640 BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP 996 < Refused RESPONDER u1 = (UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) (WI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/{ADDRESS)!(TELEPHONE! (EMS) (HOSPITAL) 1 6 03 / M 12 4 0 1 m S/ / #OCC D 71 / / UI 2 D / / 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z co N 1 El 11 1 01 ,08 /2025 06 06 ®PM in a Work Zone? ®N DIRP D 1 1T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 7 C) F.; 2 0 2 28 / ! ❑PM• ❑Construction X Z 3 0 1!>I CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM ❑Maintenance U2 o ® 11 1 ARREST NAME Obao. Everlyne. M. 11-901-A S1507000347 / ! El PM SLMT o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility 0 AM t 2 El ARREST NAME 01/08 /2025 06 57 ®PM 0 Unknown work zone type U1 45 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑y 45 1507-Ruiz.Alondra 801 02 , 11 /2025 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 -< i- ;.--__r-_--; I ( combination):or —I INDICATE NORTH p1 I 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 Not To Scale 3. Is desgned to carry 15 or fewer passengers and operated by a contract carrier I O - <____A____-I . } } . transportingemployeesInthecourseoftheirem Unit21 transportr-usll a van type vehicle or passenger tar)(orxample:employee L____a 1 II o.n..arvwy _ I. ! 4. Is used or designated to transport between 9 and 15 passengers,including the driver. N , 1. for direct compensation(example:large van used for specific purpose):or IO L L____a____. VRI i 5. Is any vehicle used to transport any hazardous material(HAZMAT)thatrequires III placarding(example:placards will be displayed on the vehicle). XI --I- CARRIER NAME —I Z ADDRESS T. CITY/STATE/ZIP g I _ MOTOR CARR.ID 0 Interstate 0 Intrastate I r ❑ Not in Comm./Govt. 0 Not in Comm./Other ; _Y____1 - USDOT NO. ILCC NO. rn 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 iD No 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 to LOCAL USE ONLY TRAILER VIN 2 m v TRAILER WIDTH(S) 0-96" 97-102" >102' m TRAILER 1 ❑ ❑ 0 Z ill TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Black Gray 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 DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE