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HomeMy WebLinkAbout2025-00001508 ILLINOIS TRAFFIC CRASH REPORT sheet 1 Df 2 Sheets 01111101111 I01101100 II liii IIIIIIIIIIIII DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00a690776 u, 1 U21 2 4 1 U1 2 U2 1 U1 1 U2 1 U1 1 U2 1 5 15 U, 1 U2 1 *P 0119 INVESTIGATING AGENCY DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY El OVER$1,500 El NOT ON SCENE(DESK REPORT) (83B Injury and for Tow Due To Crash El AMENDED YR 2025I 2025-00001508 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 mLAWRENCE AVE Elgin06:57 ® ❑ RELATED ®Y 0 N 01 07 2025 12,— ❑YES ®NO U1 g PRIVATE mo /day/yr ®PM FLOW CONDITION m FTlMI N E S W WING PARK BLVD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 u) ❑ 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 ❑EOUES ❑NW ❑ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N O n FOR DAMAGEDAREA(S) FRONT TOWED U1 Q 0 7 / p(after 1968 nd Cherokee 13-UNDER CARRIAGE 10 1 2 FIRE 0 lE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 O m F 2 SY 15-OTHER 4 ❑Y ®SNE❑UNK VEH. O AT CRASH M IN D O 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF & i�6 �i COM VEH 0 Ea 1 0 ELGIN I L 60120 0 1 0 FIRST CONTACT 11 7_: __5 *Ilsees.See Sidebar U1 Z FB75651 IL 2025 REAR TELEPHONE IL D 0 1C4RJFBG9EC416054 Kemper Insurance El ®N U2 10 . m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same 12RA000001920 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER > Refused El El 2 0 N DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 use 0 Ncv 0 Dv !1 9 5 7 Ford Escape 2020' 00-NONE 11 12 0 DUE TO CRASH ❑ 2 x oy Yr 13-UNDER CARRIAGE 10!• 2 FIRE ❑ ® 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 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i 6 i.'., COM VEH ❑ ® U1 CO FIRST CONTACT 1 7 _,__5 •IfYes.See Sidebar C ELGIN IL 60123 C 1 0 DG95047 IL 2025 FIRST Si) Z IL D 0 1 FMCUOG63LUB95404 Farmer's Insurance ❑Y ®N RDEF Xl EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X 99 9 Same 192353666 BAC $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER U1 = KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (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 El 11 1 01 ,07 /2025 06 57 ®AM in a Work Zone? ®N 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 5 n F.; T 2 ❑ 2 28 1 1 ❑PM ❑Construction X 7 Z •3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 —a, ARREST NAME / / ❑PM ' 1 ® 11 1 0 CITATIONS ISSUED ❑PENDING UtilitySLMT oN SECTION CITATION NO. ROAD CLEARANCE TIME ❑ I 2 El ARREST NAME 01 r 07 12025 07 20 0 PM 0 Unknown work zone type El AM U1 30 -r n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 30 488-Ramos.Arely 601 — r / ❑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 fight ht rating more than 10,000 pounds(example :truck or truck trailer -< ` ' ' A. I r INDICATE NORTH p1 N BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C - } (example:shuttle or charter bus):or X r 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O -- I - } } } transporting employees in the course of their employment(example:employee X i L I 1°-- transporter-usually a van type vehicle or passenger car):or CO L L.___a____� .• 4. Is used ordesi natedtotrans transport passengers,including N } } } g po passen rs,indudi the driver, = for direct compensation(example:large van used for specific purpose):or illr7 < .I. - t i. } ._ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D placarding(example:placards will be displayed on the vehicle). ,Zmt © CARRIER NAME —e 1 I riir ADDRESS Z 0 CITY/STATE/ZIP n g Not To Scale J i.- i. i. i. MOTOR CARR.ID 0 Interstate 0 Intrastate I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other ----------1 - USDOT NO. ILCC NO. rn XI Source of above z . 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 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 to LOCAL USE ONLY TRAILER VIN 2 m 0 TRAILER WIDTH(S) 0-96" 97-102" >102' T TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w White Red u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 1 TOWED BY/TO: _ . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE