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HomeMy WebLinkAbout2025-00003912 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100 II I 00 0 100 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X4 ae-3257' u, 1 U21 3 4 1 U1 2 U2 1 U, 1 1_12 1 U1 1 U2 1 1 10 u1 3 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW ' Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) El AMENDED ElB Injury and for Tow Due To Crash YR 202512025-00003912 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ® ❑ RELATED ' ' 0 N 01 18 2025 ❑AM ❑YES ®NO U1 —< VILLA ST Elgin01:21 _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m FT!MI N E S W S G I FFORD ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 2 Co ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLESOT, INVLD ❑ STOPPED U2 --I CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 NW 0!CV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 FOR DAMAGEDAREA(S) FROftf TOWED U1 0 Hodge. Destiny. R. 0 8 / yr 13-UNDER CARRIAGE ©,I �:: FIRE 0 IE < STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 m F 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 _ El N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s it 6 ii,4 COM VEH 0 0 1 00 ELGIN I L 60123 0 1 FIRST CONTACT 11 7_:, __5 *II Yes.See Sidebar U1 Z FA11380 IL 2025 REAR TELEPHONE IL Other JTDKTUD30CD527660 Shelter Mutual Ins Co ❑Y Igl N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same 12-1010451995-2 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER 73 D Refused ❑Y ❑ N 2 0 m g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 iiuv 0 i v 0 Dv 9 yr 3 Dodge Ram 1500(pickup) 2010' 00-NONE O z , DUE TO CRASH ❑ 2 73 0 13-UNDER CARRIAGE I ©Ic 2 FIRE ❑ ® U2 C M 2 4 ❑Y El IN ENGAGED 15-OTHER 9.16-TOP 3 0 X ❑N UNK VEH. AT CRASH 99-UNKNOWN *Oistrac on Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-it 6 11:, COM VEH ❑ ® U1 CO FIRST CONTACT 11 7� -5 •If Yes.See Sidebar I- ELGIN IL 60120 0 1 2637080B IL 2024 I 0 IL 1 D7RB1 CTOAS141899 Geico ❑Y ®N RDEF 73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same 6170-85-22-52 BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPOND O N U1 = KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(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 CD 11 4 01 ,18 l2025 01 21 ®PM AM in a Work Zone? NJ DIRP > co 1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 8 n 5 T 2 ❑ 2 99 + ! ❑PM. ❑Construction X R 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM ❑Maintenance U2 -, El 11 4 ARREST NAME Hodge. Destiny. R. 11-1002-E 414-993 / ! El PM SLMT o N • ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility 30 t 2 ARREST NAME AM T 1 1 ❑❑PM ❑Unknown work zone type U1 % El 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30 414-Lara. Saul tot 275-Engelke 02 , 18/2025 09 00 ❑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 -< c ` '' -' r INDICATE NORTH combination):or —I A BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C d - i. e. r (example:shuttle or charter bus):or 0 --- ----; Not To Scale I - } I- } transportinggemploo aeeslin the course 5 or fewer passengers their emplooperated nt(example:employee a contract ner transportr-usually a van type vehicle or passenger car): r w L L.___a__ ._ N 4. Is used ordesi natedtotrans rtbetween9and15passengers,includingthedriver. C `` q } } } for direct compensation(example:plarge van used for speific purose):or I I I �3 0 t l. I• _ 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires placarding(example:placards will be isplayed on the vehicle). ,Zmt - CARRIER NAME Z _ _ ADDRESS w C) cCITY/STATE/ZIPng MOTOR CARR.ID 0 Interstate 0 Intrastate I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other --- --1 - USDOT NO. ILCC NO. m XI Source of above z . ❑ Yes 0 No 0 Unknown g D Did Carrier Safety Regulations MCS)violation contribute to the crash? A ❑ Yes No ❑ 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 71 IDOT PERMIT NO. WIDELOAD'; 0 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 Gray Black 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 DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® Other/Owners Residence VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE