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HomeMy WebLinkAbout2025-00003149 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I01101100 1110111 DIV II DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0036D8509 u, 1 U21 2 4 1 U1 2 U2 1 U, 1 1_12 1 U, 1 U2 1 1 11 U1 11 U2 11 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away Elgin Police Department ONE PERSON'S 1215501-$1.500 ❑ON SCENE 15 VEHICLE/PROPERTY ❑OVER$1,500 ®NOT ON SCENE(DESK REPORT) El AMENDED ElB Injury and/or Tow Due To Crash YR 2025I 2025-00003149 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 71 FRAN KLI N ST El08:00 ® ❑ RELATED ®Y 0 N 01 14 2025 ®AM ❑YES ®NO U1 —< _ _ g PRIVATE mo !day/yr ❑PM FLOW CONDITION Ill FT l MI N E S W DUNDEE DEE AVE COUNTY PROPERTY ®Y ❑ N DOORING Ely #OF MOTOR ❑SLOW 3 Cl) ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ® STOPPED U2 --I lgi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!Cy 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C) 0 7 / Mazda CX9 2019 00-NONE ,1,_ OI_1 DUE TOCRASH ❑ EN 13-UNDER CARRIAGE 10 ' 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 r11 F 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 76.TOP 3 _ ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN V. 6 COM VEH ❑ j$J 2 CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 7 :il 4 0 F. FIRST CONTACT 12 7_;—, _5 *IIYes.See Sidebar U1 V Z Arlignton Heights IL 60005 0 1 CV74068 IL 2025 REAR TELEPHONE IL D 0 JM3TCBDY3K0323811 Geico ❑Y ign4 U2 I— in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Khan.Sulman.A. 4358904706 3 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 XI g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMV 0 NCv 0 DV !1 9 y 8 7 Honda Odyssey 2025 00-NONE 11M"i t2..-_, DUE TO CRASH ❑ 2 x 0 13-UNDER CARRIAGE 10'I 2 FIRE 0 ® U2 C c 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 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 0'i 8 �1; 4 COM VEH 0 ® U1 CO C FIRST CONTACT 6 Y��Q,__5 •IfYes,See Sidebar n BARTLETT IL 60103 0 1 0 835AB647 IL 2025 i 0 fp FL Other 0 5FNRL5H62BB102957 Alllstate ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same 811251032 BAC $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER u1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) 2 6 02 / F 13 3 0 1 0 U2 996 m / / #OCCS > / / U1 1 D / / 2 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 1 01 ,14 /2025 08 40 ®AM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C) 2 ❑ 28 11 N 3 ❑ 0 CITATIONS ISSUED 0 PENDING + ! ❑PM• ❑Construction SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 7 —a ARREST NAME / / ID ' o N ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility SLMT , 25 t 2 ARREST NAME AM 7 1 / ❑❑PM ❑Unknown work zone type U1 El OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 — El Workers present? ❑Y 25 554 Stebbins. Blake 102 , / ❑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. A CMV is defined asmotor vehicle used to transportand: r ----,5-••--, ; any passengers or property Z 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< • i.-- -i-- --; } } } r -, , ; ; , 1, ( INDICATE NORTH combination):or —I p1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } ' i 1 , } (example:shuttle or charter bus):or X 3. Is L L.___A_. 1 <-- . -___� J transporting employened to es Inhecourse 5 or fewer o their eers mplod yment example:employeener X } } } transporter-usually a van type vehicle or passenger car):or co < <.__-a-_-_, , l• < <--_-a-___� , , , , 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or 0 L L___-a____.: L L L ...._-..:_____� t i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example:placards will be displayed on the vehicle). XI --I CARRIER NAME Z ADDRESS 0 u) CITY/STATE/ZIP MOTOR CARR.ID 0 Interstate ❑ Intrastate 0 ❑ Not in Comm./Govt. ❑ Not in Comm./Other O USDOT NO. ILCC NO. m XI Source of above z . GVWR/GCWR m 0 <10,0oo 0 10,000-26,000 0 >26,000 z Were HAZMAT placards on vehicle? 0 Yes 0 No = If Yes,Name on placard O 4 digit UN NO. 1 digit Hazard class No. Xl Xl 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 VIN 1 m co LOCAL USE ONLY TRAILER VIN 2 m v TRAILER WIDTH(S) 0-96" 97-102" >102' m TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Blue 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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE