HomeMy WebLinkAbout2025-00002810 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY •X003693507*
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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 El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) El B Injury and f or Tow Due To Crash
El AMENDED
YR 2025I 2025-0000281 O VEHT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15
® ❑ RELATED ®Y 0 N 01 13 2025 ❑AM ❑YES ®NO U1 -<
SLADE AVE Elgin12:36
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION ITl
FTlMI N E S W DUNDEE AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 cn
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 —I
lgi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EDUCE ❑uuv ❑!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0
1 1 /
yr 13-UNDER CARRIAGE 10 • 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 4 rn
F 2 4 ❑Y ® n is-OTHER
SYSTEM
❑UNK VEH. AT CRASH D 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�B �i 4 COM VEH El Ea 1 0
I= FIRST CONTACT 11 7_:—__;__5 *Ilyes.See Sidebar U1
Z SOUTH ELGIN IL 60177 B 1 0 L508569 IL 2025 REAR
TELEPHONE
IL D 0 SXYZW4LA2JG554296 PROGRESSIVE El ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 1 99 9 Same 978317270 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Sherman ❑Y El 9 2 0
rg-
g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑NMv 0 NCV ❑DV
'1 9 6 0 Ford Escape 2009 00-NONE 0. Q!'-O, DUE TO CRASH rg ❑ 2 x
0 y Yr 13-UNDER CARRIAGE 10( I 2 FIRE 0 ® U2 C
c
M 2 5 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y 181 N DUNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value 9 0
POINT OF s i1 �. 4 COM VEH ❑ ® U1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 12 7 B LC-_ •UYes,See Sidebar
H CARPENTERSVILLE IL 60110 B 1 0 EN50278 IL 2025 I 0 C
IL D 0 1 FMCUO3G39KA21075 GIECO ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire 1 99 9 Same 6155173153 BAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Sherman RESPONDER igi 9 U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 4 01 ,13 ,2025 12 36 ®PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
v 2 0 2 14 01,13 ,2025 12 36 mi pM ❑Construction
R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM 0 Maintenance U2
-a, ARREST NAME KING.SANDRA. F. 11-901-A 374001289 01,13,2025 12 41 ®pM SLMT
1 ® ElUtilit 11 4 0 CITATIONS ISSUED SECTION CITATION NO. ROAD CLEARANCE TIME
PENDING
o Ny
t 2 El ARREST NAME 01!13 ,2025 01 06 ®PM El Unknown work zone type U1 30
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 30
374-Rizzu-o. Michael 201 02 !04,2025 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.
r ----r••--, , DUNDEEMVE _ : A CMV is defined as any motor vehicle used to transport passengers or property and: Z
i 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
i- ;.__-_r_-_-; 1 ® ( comWrtatlon)orINDICATE NORTH p1
f BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i JJ Not To Scale ' - (example:shuttle or charter bus):or 0SLADEvwe / / 3. Is designed to carry 15 or fewer passen ers and o rated a contract carrier O
} I } transporting employees In the course of their employment(example:employee73
' I ' transporter-usually a van type vehicle or passenger car):or CO
L f • } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver. y
`-----:----- r
for direct compensation(example:large van used for specific purpose):or o
L __L __a____- _ i t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m
i kg placarding(example:placards will be displayed on the vehicle). ;p
c - D
CARRIER NAME Z
II ADDRESS
I
1
D
+ 0
n
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CITY/STATE/ZIP g
I - MOTOR CARR.ID 0 Interstate ❑ Intrastate
I I -I-
0. . ❑ Not in Comm./OtherI
--- --1 USDOT NO. ILCC NO. rn
XI
Source of above z
. 0 Yes 0 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
P3
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 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Black Grayw
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 DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE