HomeMy WebLinkAbout2025-00002744 ILLINOIS TRAFFIC CRASH REPORT sheet 1 Df 2 Sheets 01111101111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑5501-S1,500 ®ON SCENE 14
VEHICLE/PROPERTY ElOVER 51,500 ❑NOT ON SCENE(DESK REPORT) El B Injury and f or Tow Due To Crash
0 AMENDED YR 202512025-00002744 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME
N MCLEAN BLVD Elgin 05:47 SECONDARY CRASH 15
® ❑ RELATED ®Y 0 N 01 13 2025 ®AM ❑YES ®NO U1 —<
g PRIVATE mo !day!yr ❑PM FLOW CONDITION m
FTlMI N E S W LAWRENCE AVE COUNTY PROPERTY 0 Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD DO
STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS O
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EDUCE ❑uuv ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C)
0 6 !
yr 13-UNDER CARRIAGE 1U i , 2 FIRE ❑ al E
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ]$I U2 0 m
F 2 8
❑Y SYSTEM IN ENGAGED 15-OTHER 9 76-TOP S _
El N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6_iL 6 4 COM VEH 0 j$J 1 0
~ ELGIN N I L 60123 A 1 0 FIRST CONTACT 12 7_; _5 *Yves.See Sidebar U1
Z MRL60 IL 2025 REAR
TELEPHONE
IL D 2GKFLVEK8G6350474 Country El ®N U2 93 . m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire Same P12A8690091 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Provena St.Joseph ❑Y ❑ N 3 2 ou
p; DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑row 0 NOV 0 Dv
!1 9 yf 7 Ford Fusion 2010' 00-NONE 11_"j Q�,-_, DUE TO CRASH 0 ❑ 2 x
o 13-UNDER CARRIAGE 10( I. FIRE 0 ® U2 C
M 2 4 ❑Y ❑ ❑
SYSTEM IN ENGAGED 15-OTHER 9,16-TOP 3 0 X
N UNK VEH. AT CRASH 99-UNKNOWN *Oistrac) n Value
POINT OF 8 i1�i 4 COM VEH ❑ ® U1 W
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 12 7 B .5 •(ryes,See Sidebar
— Addison IL 60101 A 1 0 ET91530 IL 2025 I 0 C
Z
IL D 3FAHPOHA9AR316337 Freeway ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire Same ILP3426627 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND❑N 3 u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 4 11 ,31 l025 05 47 ®❑pM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1 C)
ai 2 0 2 28 11 ,31 ,025 05 47 ❑PM ❑Construction *
R 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
z J ®AM ❑Maintenance U2
a1 ® 11 1 ARREST NAME Harrell, Lorelei, E. 11-902 29001182 11 ,31 l025 05 52 ❑pM SLMT
o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' ❑Utility
MI AM U1 30
r 2 El ARREST NAME 11 ,51 ,025 06 46 0 PM El Unknown work zone type
2 2 3 ❑co
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑glvl Workers present? ❑Y 30
298-Lopez, Mirko 601 21 , 01 ,025 01 30 ®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.
w' A CMV is defined as any motor vehicle used to transport passengers or property and: Z
r -- ,r••--, , \'v 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
} }---_r__--; / j combination):or —I
INDICATE NORTH p1
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- McLean78tW. 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
} } } transporting employees in the course of their employment(example:employee 73
transporter-usually a van type vehicle or passenger car):or CO
4. Is used or designated to transport between 9 and 15 passengers,including rCjt
} for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or o
L L___-a____. s - l. l. I 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
I j placarding(example:placards will be displayed on the vehicle). ;p
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,\ CARRIER NAME Z
i. O
/ - / ADDRESS Durns �i of
i. 4.
CITY/STATE/ZIP 0
I I I I _ MOTOR CARR.ID Interstate Intrastate
I I .4-
Q 0 Not in Comm./Govt. Not in Comm./Other
llll I‘I. -- - __ USDOT NO. ILCC NO. <
m
XI
Source of above z
. 0 Yes II No ❑ 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
0
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
White Red
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
Arties/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE