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HomeMy WebLinkAbout2025-00001268 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I01101100 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003650852' u, 9 U21 3 4 1 U1 2 U2 1 u,99 1_12 1 u,99 U2 1 4 10 u, 3 U2 1 *P 0119 INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 14 VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00001268 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 mS STATE ST Elgin 05:37 ® ❑ RELATED ®Y 0 N 01 06 2025 ❑AM ❑YES IX]NO U1 -< _ _ PRIVATE mo !day!yr ®PM FLOW CONDITION MFT!MI N E S W WALNUT AVE COUNTY PROPERTY El ® N DOORING ❑y #OF MOTOR IR SLOW 15 ' ❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 —I CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEON. 0 EWES 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C) FOR DAMAGEDAREA(S) FRO T TOWED VI U1 0Unknown,O. / / Unknown Unknown 00-NONE ©, 12 , DUE TO CRASH ❑ NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE IE 10.I !�. 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ]$I U2 0 in SYSTEM IN ENGAGED 15-OTHER 916.70P 3 9 9 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s it 6 1i C.OM VEH 0 )g! 1 O H 11 FIRST CONTACT 7_;-__;_5_ *IIYes.See Sidebar U1 0 9 0 UNKNOWN RE 2 Z _ TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 11/ 15 unknown 0 Y 0 N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same unknown 1 rn `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER en Refused 0 Y ® N 99 0 m x DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES 0 NW 0 KCv 0 DV /1 9 9 2 Lincoln MKX 2007 oo-NONE ,�_' 12...�DUE TO CRASH ❑ 2 0 13-UNDER CARRIAGE 10 2 FIRE El ® U2 C F 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X 0 Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN `0istracllon Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s-it 6 1l, COM VEH ❑ ® U1 CO FIRST CONTACT 1 Y ,__5 •(ryes,See Sidebar H E LG I N IL 60120 0 1 0 EQ38003 IL RFJ M IL 2LMDU88C77BJ12516 STATE FARM ❑Y ®N RDEF71 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same 1213265-SFP-13 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER u1 = iUNIT) (SEAT) (DOBi (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 2 4 08 / :A / / UI 1 D / / 3 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 1 01 /06 l2025 01 06 ®❑PM in a Work Zone? ®N DIRP co 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 Eri 2 0 28 25 N 3 0 ❑CITATIONS ISSUED 0 PENDING + ! ❑PM• ❑Construction SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 7 -a ARREST NAME / / ❑PM ' I ® 1 1 1 ❑CITATIONS ISSUED PENDING Utilit SLMT , o N SECTION CITATION NO. ROAD CLEARANCE TIME 0 y 0 AM t 2 0 ARREST NAME 01/06 /2025 05 37 ®PM 0 Unknown work zone type U1 35 n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 35 1535 Solis• Laura 701 334-Fries / ❑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 truckrtrailer -< ` ` ' ' ® r INDICATE NORTH combination)or .Z�1 Not To Scale BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C -� _ } (example:shuttle or charter bus):or X 3. Is designed to carry15 or fewer passengers and operated a contract carrier O }----------i ii I. } } transporting employee in the course of their employment(example:employee X transporter-usually a van type vehicle or passenger car):or w L L.__-a-_ ‘41 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( 9 Pe or L L____a____. �'� t t i. i 5. Is any vehicle used to transport anyhazardous material(HAZMA that requires m �I - placarding(example:placards will be isplayed on the vehicle). ;p r CARRIER NAME —I Z _1. i ._ ADDRESS 0 /f 0 CITY/STATE/ZIP MOTOR CARR.ID ❑ Interstate ❑ Intrastate I I T ❑ Not in Comm./GaA. Not in Comm./Other �"-------1 - USDOT NO. ILCC NO. rn XI Source of above z . 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 0 TRAILER WIDTH(S) 0-96" 97-102" >102' T TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 ❑ O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Silver Black u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 9 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