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HomeMy WebLinkAbout2025-00003897 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100 0111111111 0 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY Xooa69 402' U1 1 U21 1 1 1 u, 2 U2 1 u, 1 u2 1 u,99 U2 99 1 15 u1 1 u2 1 *P 119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El5501-S1,500 ®ON SCENE 14 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash El AMENDED YR 202512025-00003897 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 mVILLA CT El in12:05 ® ❑ RELATED ®Y 0 N 01 18 2025 ❑AM ❑YES ®NO U1 _ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION m FT!MI N E S W E CH ICAGO ST COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR El SLOW 1 cn ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ® FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUCE 0 uuv 0!Cy 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C) Ozbirn. Mary. E. 0 9 / yr 13-UNDER CARRIAGE ©,I• !�. 2 FIRE 0 lE 10STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 0 m F 2 SY4 ❑Y El ®UNK VEH. 9 AT CRASH M IN D 9 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8, i�S �i 4 COM VEH 0 j$J 1 0 ELGIN IL 60120 0 1 FIRST CONTACT 11 7_; __5 *Ilsees.SeeSidebar U1 Z 3832861B IL 2025 REAR M TELEPHONE IL D 1 FTEW1 EG9HFB99106 Erie INsurance ❑Y Igl N U2 13 . m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same Q082821393 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER > Refused El El 2 0 p; DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 iiuv 0 i v 0 DV !1 9 yf 1 Nissan Altima 2016 00-NONE N__' 12.,.®DUE TO CRASH rg ❑ 2 o 13-UNDER CARRIAGE 10 2 FIRE ❑ ® U2 C M 2 4 SYSTEM IN 9 ENGAGED 9 15-OTHER 916-TOP 3 ❑Y ❑N ®UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value Q U1 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-it _ Il, 4 COM VEH 0 ® W FIRST CONTACT 1 YA-O__{ _5 •• •Iryes,See Sidebar — Freeport IL 61032 0 1 EL82095 IL 2025 RFJ 0 N Z IL D 1 N4AL3AP2GC219369 Geico ❑Y ®N RDEF M EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X Same 6125-86-76-86 BAC $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPOND O N u1 = (UNIT) (SEAT) (DOB1 (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) U1 1 D / / 1 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 ,18 l2025 12 05 ®PM in a Work Zone? ®N DIRP co 1 1 PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 3 C) T o", 2 0 2 28 ) ! ❑PM• ❑Construction * Z 3 0 1!>I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM 0 Maintenance U2 o1 ® 11 1 ARREST NAME Ozbirn. Mary. E. 11-601-Ax SO430-000450 / ! ❑PM SLMT o N 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility 30 1 2 0 ARREST NAME AM T 1 r ❑❑PM 0 Unknown work zone type U1 n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 430-Nemt�ev.Sergey 101 - , / ❑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•---, , I I A CMV is defined as any motor vehicle used to transport passengers or property and: Z r I I combination): r more thanpound (example:truck or truck/trailer 1. Hasaweight rating10,000 5 -< INDICATE NORTH o p3 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C (example:shuttle or charter bus):or 0 3. Is L i_ -A- -.i ® - 7 } r } transporting mploned to aeeslin hecourse5 or fewer�ofther employment example:employee a contract rier X I BaaOadomMt..1 1 I I transporter-usually a van type vehicle or passenger car):or w L L.___a.._.- II. } } } •4. Is used or designated to transport between9and15passengers,includingthedriver. C for direct compensation(example:large van used for specific purpose):or 0 L____a..... iL } } } _ 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires — um t- Unit i placarding(example:placards will be isplayed on the vehicle). m n)-- ::s. - - - 2# �� r� CARRIER NAME Z O I I I I - ADDRESS II T. , O CITY/STATE/ZIP g r' C - MOTOR CARR.ID 0 Interstate 0 Intrastate I T ❑ Not in Comm./Govt. 0 Not in Comm./Other ----- ----1 I USDOT NO. ILCC NO. C XI Source of above z . 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?El❑ Yes II 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 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 Gray u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 2 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: 2 TOWED BY/TO: DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE