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HomeMy WebLinkAbout2025-00004678 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I01101100 11111 II III IIIIII DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV XO03 OO9 u, 1 u21 3 4 3 UI U2 1 u, 1 1_12 1 u, 1 U2 1 1 11 u, 15 U2 11 *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 ®5501-$1.500 ®ON SCENE 3 VEHICLE/PROPERTY ❑OVER 51,500 ❑NOT ON SCENE(DESK REPORT) El AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00004678 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 6 mN STATE ST Elgin08:47 ® ❑ RELATED ❑Y ®N 01 22 2025 ®AM ❑YES IX]NO U1 PRIVATE mo /day/yr ❑PM FLOW CONDITION ITl • 1 O !MI N E S BigTimber Rd COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 C/) ® © Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 —1 ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ® FREE FLOW # LNS 0 18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUCE 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n 0 3 ! yr 13-UNDER CARRIAGE 10 12! 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED THER ❑ 0U2 2 171 M 2 4 SYTM❑Y ®SNE❑UNK VEH. 0 ATCRASHD 0 15-99-UUNKNOWN 9 16•TOP 3 `Distraction Value 9 ALGN X. r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s ij 4 COM VEH 0 Ea 1 C) F. FIRST CONTACT 12 7__�B_,__5 *IIYes.See Sidebar U1 0 Z Belvidere IL 61008 0 1 0 XE13356 IL 2025 1> TELEPHONE IL D 1 GC1 YN E77LF165724 Travelers Property Casual ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m Emkay Inc trust VTC2JCAP5835B82ATIL2 3 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER !1 9 yf 7 Toyota Camry 2007 00-NONE 1i_"j 12..-_1 DUETO CRASH ❑ 0 2 x o _ 13-UNDER CARRIAGE 10 1 2 FIRE ❑ ® 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 •Oistraellon Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 5 iI S I,,_4 COM VEH D ® tit CO FIRST CONTACT 6 Y__{_O ._5 •(ryes,See SidebarC ~ ELGIN IL 60120 0 1 0 FB43740 IL 2025 i 0 IL D 4T1 BE46K97U636716 Kemper ❑Y ®N RDEF M EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X Torres.Arlene 12A0001575509 BAC $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP u1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME))(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 2 6 09 / :A / / UI 1 D / / 3 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 1 1/ r 2/ l025 08 47 ®❑PM in a Work Zone? ®N DIRP co 1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 � o" 2 ❑ 11 28 r r ❑PM• ❑Construction 1 Z3 0 xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 3 o1 ® 11 1 ARREST NAME Franta.Justin. P. 11-601-Ax W410000688 ! ! ID PM SLMT o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility 30 t 2 ARREST NAME AM r r ❑❑PM ❑Unknown work zone type U1 El 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑Y 30 410-DeLeon.Jessica 501 272-Bajak r / 0 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 e---•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 truckrtrailer -< c ` '' -' r INDICATE NORTH combination):or -I M I I I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C i_ ; _nbrraspw_i _ ,. (example:shuttle or charter bus):or r r 0 e r„wr I I 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I - } } } transporting employees In the course of their employment(example:employee X _ I I transporter-usually a van type vehicle or passenger car):or co Lett 2.L � .J.L._..' 4. Is used or designated to transport between 9 and 15 passengers,including the driver. C } for direct compensation(example:large van used for specific purpose):or O < a '.11111114141 I I I - } . , 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires D placarding(example:placards will be displayed on the vehicle). XII I I , , Z CARRIER NAME Z ADDRESS 0 C) CITY/STATE/ZIPg MOTOR CARR.ID 0 Interstate 0 Intrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other --- --1 - USDOT NO. ILCC NO. m Xl Source of above z . ❑ Yes ❑ 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 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 Yellow Black u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 0 TOWED BY/TO: _ SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE