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HomeMy WebLinkAbout2025-00004680 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 nit DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003700%0 u, 1 U21 3 4 3 U1 4 U2 1 u, 1 1_12 1 1.11 1 U2 1 1 11 u1 1 U2 1 *P 0 1 1 9* INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW ' Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 11 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and f or Tow Due To Crash YR 202512025-00004680 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ® ❑ RELATED PRIVATE ❑Y ®N 01 22 2025 ®AM ❑YES IX]NO U1 RT20 WB Elgin mo /day/yr 08:35 ❑PM FLOW CONDITION m I O ®!MI N E S © East S MCLEAN BLVD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR NISLOW 1 cn Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL ❑EWES ❑uuv ❑!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 C) 1 2 / yr Kia Motors Co4oul 2011 00-NONE Q• �I 7T OUETOCRASH ❑ �:/ 13-UNDER CARRIAGE 10 1 EN 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 3 <<T1 M 2 SY4 ❑Y ®SNE❑UNK VEH. 0 AT CRASH M IN D 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�S �i 4 COM VEH 0 j$J 2 O 1 . Elk Grove Village IL 60007 0 1 0 FIRST CONTACT 11 7 : -5 *II Yes.See Sidebar U1 Z 98643563 IL 2025 ' E TELEPHONE IL D 0 KN DJT2A27B7211990 Progressive ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR 99 9 Same 969915842 3 m `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER > Refused ❑Y ® N 2 0 N DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 uv 0 NOV 0 DV 1 9 6 0 Toyota Sienna 2014 00-NONE 'o,1 t2 c,-2 FIRE DUE O CRASH 0 ® U2 2 C o 13-UNDER CARRIAGE ii F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X ❑YNi N DUNK VEH. AT CRASH 99-UNKNOWN *OistracI on Value 9 3 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 5 1 S t. 4 COM VEH ❑ ® Ut CO FIRST CONTACT 6 O7 ,�=Q OS •IfYes.See Sidebar C ELGIN Z IL 60123 0 1 0 BK86963 IL 2025aR 0 fn • M IL D 0 STDYK3DC9ES411078 Direct Auto ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X 99 9 Same PAIL001232128 BAC • $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER u1 = (UNIT) (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 ® 11 1 11 ,21 )025 08 51 ®❑AM in a Work Zone? ®N DIRP co 1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM •U1 C) 0 2 ❑ 28 11 ) ) ❑PM• ❑Construction * Z •3 0 lyg CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 o ® 11 1 ARREST NAME Truman.Jacob. K. 11-601-Ax 1540000086 r r El PM SLMT o N 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility AM U1 50 t 2 ❑ ARREST NAME 11 +51 1025 09 35 [M PM ❑Unknown work zone type n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 - ❑AM Workers present? ❑Y 50 1540-Allah. Muhammad 701 , ❑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 -I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C _ } (example:shuttle or charter bus):or X 3. Is desgned to carry 15 or fewer passengers and operated by a contract Garner I O ,.,ex.,..a a - I. } } transporting employees In the course of their employment(example:employee X transporter-usually a van type vehicle or passenger car):or w L }-----}----; - } 1- } •4. Is used or designated to transport between 9 and 15 passengers,including the driver. N for direct compensation(example:large van used for specific purpose):or L L____a____.: ...-_ 4. � 4 � 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m placarding(example:placards will be displayed on the vehicle). ;p CARRIER NAME —1Z i. ADDRESS 0itT. Not 7b Scale I CITY/STATE/ZIP 0 g MOTOR CARR.ID 0 Interstate 0 Intrastate 0 I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other --- --1 - USDOT NO. ILCC NO. m XI Source of above z If Yes,Name on placard 0 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 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 Green Red u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 2 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/TO. DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE