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HomeMy WebLinkAbout2025-00001956 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I01101100 II 0 I II IIIIIIIIIIIII DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003689701 u, 1 U21 2 4 1 u, 2 U2 1 u, 1 1_12 1 U1 1 U2 1 1 15 u1 1 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 14 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) El Injury and f or Tow Due To Crash El AMENDED YR 2025I 2025-00001956 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n N EDISON AVE Elgin03:15 ® ❑ RELATED ®Y 0 N 01 09 2025 ❑AM ❑YES ®NO U1 g PRIVATE mo /day/yr ®PM FLOW CONDITION m FT!MI N E S W W CH ICAGO ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 u) ❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!Cy 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0 0 4 / yr 13-UNDER CARRIAGE lE 101 ! 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 0 m F 2 8 ❑Y ®SNE❑UNK VEH. 0 AT CRASH IN ENGAGED0 99-UUNKNOWN 0916-TOP S `Distraction Value 9 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 0 i� 6 �'.4 COM VEH 0 j$J 1 n ~ Morton Grove IL 60053 0 1 0 FIRST CONTACT 8 (1)-; --5 *If Yes.See&debar U1 0 Z A716205 IL 2025 REAR TELEPHONE IL D 0 JTHBJ46G782227346 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 1258811-SFP-13 1 r "o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ElY ElN 2 0 N DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uv 0 NCv 0 DV yr Q 2 !� 0 13-UNDER CARRIAGE 10 j ©I 2 FIRE ❑ El U2 C F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16•TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-it 6 1l, COM VEH D ® U1 CO FIRST CONTACT 1 Y _, _5 •(ryes,See Sidebar H ELGIN z IL 60123 0 1 0 ED89957 IL I C 0 Si) M IL 0 1 C4RDJAG8HC666935 Allstate ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X 99 9 Same 974448227 BAC $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER 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 El U2 Z N 1 CD 11 4 11 ,12 /25 03 15 ®AM in a Work Zone? NJ DIRP co 1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 o" T 5 n 2 ❑ 2 18 1 / ❑PM. El Construction X r' 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 ❑AM ❑Maintenance U2 au ® 11 4 ARREST NAME Nikodem.Choon.J. 11-901-A S1542-000064 / r ❑PM SLMT o N 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' ❑Utility AM r 2 ❑ ARREST NAME 11 112 125 04 01 ®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 1542-Chase. Ethan 601 21 r 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 as any motor vehicle used to transport passengers or property and: Z N 01. Has a weight rating more than 10,000 pounds{example:truck or truck trailer -< } ;----; ll } combination):or INDICATE NORTH p1 i_ ` I -:. i . Not To Scale 1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C (example:shuttle or charter bus):or - ------;----; I ) transporting employeened to s Inthe course 5 or fewer passengers rhea emaployment nd operated xample:employee transporter} } } i. i. __}----+ �� ` - } } } • sed or des gnated to transport betweelly a van type vehicle or n 9 and r 1 passengers,including the dryer, co Unit 2 for direct compensation(example:large van used fors specific purpose):or to < <--_- -___. t 1 °�---` - i. < i. L 5. Is any vehicle used to transport an hazardous material(HAZMAT)tha requires M a — — — .. Imi — — placarding(example:placards will be y displayed on the vehicle). m X) —1 CARRIER NAME Z IADDRESS n CITY/STATE/ZIP MOTOR CARR.ID 0 Interstate ❑ Intrastate rI ❑ Not in Comm./Govt. Not in Comm./Other ------- --1 - USDOT NO. ILCC NO. rn XI Source of above Z . If Yes,Name on placard 0 4 digit UN NO. 1 digit Hazard class No. 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 M 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 0 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Gray Gray u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT' 3 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: 2 TOWED BY/TO: DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE