HomeMy WebLinkAbout2025-00002792 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100 1111111 00100
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00a693615
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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 3
VEHICLE/PROPERTY ❑OVER 31,500 El NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
0 AMENDED YR 2025I 2025-00002792 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 -n
ALFT LN Elgin
® ❑ RELATED ❑Y ®N 01 13 2025 ®AM ❑YES ®
PRIVATE NO U1
mo /day/yr 10:44 ❑PM FLOW CONDITION m
_
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 15 cn
232 0/MI O E S W Alft Ln WITH VEHICLES INVLD 0 STOPPED U2 --I
ElAT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑V ® N PEDALCYCLIST®N ® FREE FLOW # LNS 0
gi DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 5 C)
FOR DAMAGEDAREA(S) FRONT TOWED U1 O
Diana. Kevin.C. 1 1 /
yr 13-UNDER CARRIAGE 10 !�. 2 FIRE 0
NI
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED IDr1 0 U2 5 r<
M 2 SY n is-OTHER
4 ❑Y ®SNE❑UNK VEH. AT CRASIN n H 99-UNKNOWN 9 16•TOP 3 `Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ ;il S 4 COM VEH 0 Ea 1 0
F. FIRST CONTACT ;� __
12 75 *I(Yes.See Sidebar U1
Z Aurora IL 60503 0 1 0 48146CV IL 2025 ,
TELEPHONE
IL D 1FTYR1ZM3KKA74217 Cincinnati Ins Co ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Advocate Health Care EBA0686403 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
98 c
g DRIVER ❑ PARKED ❑DRIVERLESS 0 RED ❑PEDAL 0 EWES ❑ ivy 0 Ncv 0 DV
1 9 yr76 Nissan Pathfinder 2024 00-NONE 11. t2 c,_2 FIREo CRASH ® U2 2 73
C
13-UNDER CARRIAGEID Ti
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN •Oistracton Value 0
POINT OF 8 i 4 COM VEH ❑ ® U1 IN
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR -j -L
FIRST CONTACT 6 Y.-t{,--Li...- -6 •If Yes,See Sidebar
BARTLETT IL 60103 B 1 0 FTBALR6 IL 2025 ' 0
IL D 5N1 DR3DJ2RC233395 American Financial Allian ❑Y ®N RDEF Z1
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire 99 9 Same AICA715426 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER 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 0 Y U2 Z
N 1 ® 11 1 11 ,31 ,025 10 44 ®❑pM in a Work Zone? ®N DIRP co
1 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 03 99 11 ,31 ,025 10 44 pm
❑ ❑Construction
Z 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
®AM ❑Maintenance U2
-a ARREST NAME 11 ,31 l025 10 50 ❑PM "
,
1 ® 11 1 0 Utility
❑CITATIONS ISSUED ❑PENDING SLMT
o N SECTION CITATION NO. ROAD CLEARANCE TIME
MI AM U1 45
r 2 ElARREST NAME 11 '31 1025 10 44 0 PM ❑Unknown work zone type
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 45
481-Rodriguez. Hannah 901 402-Free , , ❑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.
I I A CMV is defined as any motor vehicle used to transport passengers or property and: Z
r r....�,.....�
Ural I I 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
i- ;.---_r----; � ( combination):or
as i I INDICATE NORTH
I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
C'1_I - } r r r (example:shuttle or charter bus):or 0
• "rI I I A 3. Is designed to carry15 or fewer passengers and operated a contract carrier O
pa 9 pe by
�► t N } } } transporting employees in the course of their employment(example:employee X
V I T ( transporter-usually a van type vehicle or passenger car):or C
MS r.ann
< <.___a____. onus `"' } } 1 •4. Is used or designated to transport between 9 and 15 passengers,including the driver. to
1 ♦ for direct compensation(example:large van used for specific purpose):or i iO
_ 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
• placarding(example:placards will be displayed on the vehicle). m
♦ ;0
CARRIER NAME Z
ADDRESS 0
w
CITY/STATE/ZIP 00
... I II 1; - MOTOR CARR.ID 0 Interstate El Intrastate
' ❑ Not in Comm./Govt. ❑ Not in Comm./Other 00
i— --- '-4 I USDOT NO. ILCC NO. m
m
XI
Source of above z
. • m
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? A
❑ Yes II El Unknown C
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 VIM 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 ❑ ❑ ❑ z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
White White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 0 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE