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HomeMy WebLinkAbout2025-00001108 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets III III 11 IIII IIIIII 01100 HI HI OUI 100 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003650863 u, 1 U2 1 1 7 U1 1 U2 U, 1 1_12 U, 1 U2 5 6 U1 1 U2 *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 El$501-$1.500 ®ON SCENE I VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash 0 AMENDED YR 202512025-00001108 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n 436 RAYMOND ST El In03Ag ® ❑ RELATED ❑Y ®N 01 06 2025 ®AM ❑YES ®NO U1 -< _ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW Cl) ❑ FT/MI NESW Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS O Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUCE 0 uuv 0 Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0 0 4 / yr 13-UNDER CARRIAGE p) 2 FIRE ❑ ® C STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O O DISTRACTED 0 ]$I U2 m M 2 4 ❑Y ®SNEM Uis-OTHER NK VEH. O AT CRASH IN ENGAGEDO 99-UNKNOWN 9©TOP 3 `Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF & it 6 !. 4 COM VEH ❑ Ea 1 0 ~ ELGIN I N I L 60120 0 1 0 FIRST CONTACT 12 t _al _O •II Yes.See Sidebar U1 0 Z EK89055 IL 2024 REAR TELEPHONE IL D 0 JH4DC530545018231 COUNTRY FINANCIAL ❑Y ®N U2 M 5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR co Same P010627990 4 m o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ❑ N 2 0 ❑ DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 Nuy 0 i v 0 DV CIRCLE NUMBER(S) U1 yr 12 _ 71 o 13-UNDER CARRIAGE 10.i :., 2 FIRE ❑ 0 U2 C c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 ❑ ❑ SPDR 0 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value U1 9 - POINT OF s-.;, 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT TA—d:-5 C•IO e1sVEH See •Sidebar❑ 0 C CO F` ---- co M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O ❑Y ❑N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER I = BAC HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < RESP❑YD❑N NDER U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0 / / U2 r m Pj 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 43 5 City of Elgin.City.o. Tree 01 ,06 ,2025 03 49 ®❑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 .. v t 2 ❑ 150 DEXTER CT ELGIN IL 60120 11 11 01!06 ,2025 03 56 ❑pM ❑Construction >F Z3 0 ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ®AM ❑Maintenance U2 -a, ARREST NAME 01,06,2025 04 01 ❑pM u 1 ❑ ❑CITATIONS ISSUED ❑PENDING UtilitySLMT o SECTION CITATION NO. ROAD CLEARANCE TIME o N - ❑ AM U1 30 t 2 ElARREST NAME 01!06 12025 04 17 [M PM ❑Unknown work zone type cf T n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y 2 3 CI - ❑AM Workers present? ❑ 1516-Mancera. Maria 401 , 0 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 i----r-•--, A CMV is defined as any nmtor 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__-_; I combination):or 0 INDICATE NORTH71 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver n - } (example:shuttle or charter bus):or A I 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier O } } } transporting employees In the course of their employment(example:employee .(] transporter-usually a van type vehicle or passenger car):or w 73 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 O III L L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example:placards will be displayed on the vehicle). m ;0 �► CARRIER NAME Z �t`'`' __ ADDRESS 6) 0 CITY/STATE/ZIP th T. _ MOTOR CARR.ID 0 Interstate 0 Intrastate ® ❑ Not in Comm./Govt. ❑ Not in Comm./Other 00 :- ‘I. --- --1 () - - USDOT NO. ILCC NO. m m 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 M D Did Carrier Safety Regulations MCS)violation contribute to the crash? ❑ Yes II No 0 Unknown 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 co 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_COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Black u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO. _Redmons/Owners Residence . SELECT CODES FROM THE BACK OF CRASH BOOKLET U_TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO: DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE