HomeMy WebLinkAbout2025-00002497 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Of 4 Sheets II 111 11 1����� mil 01100 lflhilil
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00a693688
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INVESTIGATING AGENCY DAMAGE TO ANY ®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 2
VEHICLE/PROPERTY El OVER$1,500
El NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00002497 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 m
64 S CHANNING ST Elgin11:23
® ❑ RELATED ❑Y ®N 01 11 2025 DAM ❑YES El NO U1 —<
_ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 3 Cl)
❑ FT l MI N E S W 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 O PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 ION 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
FOR DAMAGEDAREA(S) FROF tf TOWED U1 Q
NAME(LAST,FIRST,M) Welch.Stacy. M. 0 6 /
yr 13-UNDERCARRIAGE 101 !. 2 FIRE 0IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
F 2 SY 15-OTHER
4 ❑Y ®SNE❑UNK VEH. 0 AT CRASH M IN D 0 99-UNKNOWN 9 76•TOP 3 *Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ 1 a �i 4 COM VEH 0 0 1 0
F.
Elgin I L 60120 0 1 0 FIRST CONTACT 1 7 . __5 *if Yes.See Sidebar U1
Z 9 9HIA037 CA 2025 Ismi
TELEPHONE
CA C 0 5FNRL38816B096094 Progressive ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Schimri.Tyha 928538715 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 XI
0 DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMv 0 KCv 0 DV
yr Dodge Caravan(inc Grand)2012 00-NONE 11 O 12.._-1 DUE TO CRASH ❑ (� 2 x
0 13-UNDER CARRIAGE ( 2 FIRE 0 El U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR C)
SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 9 0 X
a ❑ El i N UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value
POINT OF 8 -4 Ut
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 1 O 7-, S L__5 C•OM
® W
~ C
DA79225 IL 2025 REAR 0
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
2C4RDGCG5CR104345 Stonegate ❑Y J N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
99 9 Franco.Juan. L. ILSP0006665 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOD) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
0 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 18 1 co
u 01 ,11 l2025 11 23 ®PM AM in a Work Zone? ®N DIRP >
I I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
2 0 15 18 01,11 /2025 11 23 PM
® • ❑Construction
1 5
R 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2
—a, ARREST NAME / / _ El PM '
1 ® 1 1 1 ❑CITATIONS ISSUED ❑PENDING - • UtilitySIMT
o N SECTION CITATION NO. ROAD CLEARANCE TIME 0
t 2 0 ARREST NAME 01 r 11 l2025 11 50 0 PM El Unknown work zone type U1 300 AM
ncf 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 30
1527-Juarez.Jorge 301 310-Zierk , / ❑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••--, , N 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 -<
i- }-- -'-- --' _I • INDICATE NORTH combination):or -I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
"' } (example:shuttle or charter bus):or 0
7 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O
I- <___-A-__-i ,�«o y - } } } transportingemployees In the course of their employment
64?S.?Channing?St •n transportr-usuall a van type vehicle or passen car (orxample:employee C
i_ }-----;----; -,,- - • } } } •4. Is used or designated to transport between 9 and 15passengers,including the driver,
° for direct compensation(example:large van used fors specific purpose):or
L L-__-a y y _ - t i. 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
Ira o placarding(example:placards will be displayed on the vehicle). ;p
I cn
cn .
I CARRIER NAME Z
Dupage?St • I g _ ADDRESS D
C
>
ly CITY/STATE/ZIP g
11 I I I C MOTOR CARR.ID 0 Interstate 0 Intrastate
Not To Sce/eJ Dupage?St I T 0
l c ❑ Not in Comm./Govt. ❑ Not in Comm./Other
l as C
;____Y____ ct1i. USDOT NO. ILCC NO. m
XI
Source of above z
: Form Number 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' -n
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 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: 1 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 0 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE