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HomeMy WebLinkAbout2025-00003453 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets _ 01111101111 01101100 111001 00 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0036.1281 u, 1 U2 1 1 1 U146 u2 U, 1 1_12 U, 1 U2 1 1 9 U1 17 U221 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 7 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) 0 AMENDED ® B Injury and/or Tow Due To Crash YR 202512025-00003453 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn 1975 LIN LOR LN El08:58 ® ❑ RELATED ❑Y ®N 01 16 2025 ®AM ❑YES ®NO U1 —< _ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m COUNTY PROPERTY ®Y 0 N DOORING ❑y #OF MOTOR El SLOW 1 cn ❑ FT/MI NESW Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 g DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES ❑NW ❑!Cy 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 99 n 0 9 / yr 0-UNDERCARRIAGE ©,i ,•: FIRE ❑ alE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ ]$I U2 m F 2 SY is-OTHER 4 ❑Y ®SNE❑UNK VEH. O AT CRASM IN H 0 99-UNKNOWN 9 16•TOP 3 `Distraction Value ALGN 2 • r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�a 4 COM VEH 0 Ea 1 0 ~ ELGIN IL 60123 0 1 0 FIRST CONTACT 12 7_; __5 *lIVes.SeeSidebar Ut Z BN97072 IL 2025 REAR TELEPHONE IL D 0 4T1BE46K28U223831 AAA ❑Y ® 4 U2 93 . m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m co Elgin Fire 99 9 Same AUT701627472 2 r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Provena St.Joseph ❑Y El 2 0 p DRIVER I} PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 row 0 Ncv 0 DV yr Hyundai PALISADE 2020' 00-NONE 11-I Qj O DUE TO CRASH 0 ❑ 1 .� 13-UNDERCARRIAGE I FIRE ❑ ® U2 c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10• I�O DISTRACTED ❑ ® SPDR n SYSTEM IN 0 ENGAGED 0 15-OTHER 9.19-TOP 3 0 a ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value POINT OF sit "4 Ut N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR A 6 l.',._ C. VEH ❑ ® CO FIRST CONTACT 1 Y -5 •If Yes,See Sidebar H BT26146 IL 2025 I0 Si) M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 KM8R14HE2LU051584 Progressive ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Clooney.Jennifer. L. 942504395 BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z u 1 ® 18 01 ,16 /2025 08 59 ®❑PM in a Work Zone? ®N DIRP co 1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1 C) 453. 2 0 15 99 01,16 ,2025 08 59 PM ❑ ❑Construction * Z 3 0 ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ®AM ❑Maintenance U2 ARREST NAME 01,16/2025 09 09 ❑PM o N ® 11 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT 10 t 2 ARREST NAME AM 7 1 r ❑❑PM 0 Unknown work zone type U1 El OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 99 495-Sjodir.Jacob 602 275-Engelke , ❑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••--, , ; 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 truck trailer -< ` ` --I -' r INDICATE NORTH combination):or .Z-1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C i_ - } r (example:shuttle or charter bus):or 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I A O } } } transporting employees in the course of their employment(example:employee X transporter-usually a van type vehicle or passenger car):or w L L.___a__ 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including C} for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or O L L.._-a____. '^'"""'"" WW1 t i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m placarding(example:placards will be displayed on the vehicle). ;p D CARRIER NAME Z Z „� ADDRESS 0 fiat m .r so1 , • , • , D • CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate 0 Intrastate 0 I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other ‘I. - --• - USDOT NO. ILCC NO. m 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 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 Beige Blue u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. _Mies/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY1T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE