HomeMy WebLinkAbout2025-00004989 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0037022 9
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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 El$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500
El NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00004989 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 mDUNDEE AVE Elgin
® ❑ RELATED ❑Y ®N 01 23 2025 DAM ❑YES ®NO U1 —<
PRIVATE mo /day/yr 04:09 ®PM FLOW CONDITION m
_
®10(�!MI N EON KI M BALL St COUNTY PROPERTY ElY ® N DOORING El #OF MOTOR 0 SLOW 99 Cl)
Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
18:DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
Salerno. Michael.J. 1 2 /
yr 13-UNDER CARRIAGE fa !�. 2 FIRE 0
NI
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 2 m
M 2 SYTHER
4 ❑Y ®SNE❑UNK VEH. 0 AT CRASH M IN ENGAGED0 99-UNKNOWN 9 76-TOP S `Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 i� 6 �I COM VEH 0 0 1 n
V. Z YORKVILLE IL 60560 0 1 0 FIRST CONTACT 5 T : _� 'If Yes.See Sidebar u10
V212527 IL 2025 E
TELEPHONE
IL D 0 4S4WMAFDXM3404163 STATE FARM ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 2609031SFP13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y El 2 0
p; DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑ uv 0 NCv ❑DV
yr I 2
...
13-UNDER CARRIAGE 10( I 2 FIRE 0 ® U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR 0
SYSTEM IN ENGAGED 15-OTHER 9.16-TOP 3 0
a 9 9 0 Y 0 N 0 UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value
POINT OF 6 4 tit
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 12 �-. 6 1`_6 CIOMVSeeSideear❑ ® CO
~ 0 9 UNKNOWN RE C
9sn
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
UNKNOWN UNKNOWN ❑Y ❑N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same UNKNOWN BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 01 ,23 /2025 04 09 ®PM in a Work Zone? ®N 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 3 n
T
Si 2 0 2 03 ! ! ❑PM ❑Construction X
Z 3 0 ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
—a, ARREST NAME / / ID PM '
1 ® 1 1 1 ❑CITATIONS ISSUED ❑PENDING SLMT
o u SECTION CITATION NO. ROAD CLEARANCE TIME
ElUtilit y
r 2 El ARREST NAME 01!23 /2025 04 09 ®PM El Unknown work zone type U1 0 AM
35
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ID ❑AM Workers present? ❑Y 35
456-Romalo.Carmine 301 — ! ! ❑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
N 1. Has a weight rating more than 10,000 pouds(example:truck or truck trailer -<
c ` --I -' T r INDICATE NORTH comWrtation)or
i
/ BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
r r ,. (example:shuttle or charter bus):or 0
Ov4�9Aw 0
L L.__-A-. w.rne J0
I transporti3. Is ng employened to es 5 or fewer Inhecourseeo theirmers ployd ment example:employeener X
< ...I. - J I / . } 1 4.transporter
used or designated to transport between 9 and 15 passengers,including the driver,
} }
} 1. •
for direct compenation(example:large van used for speific purose):or
L L____a----. i. < i. L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
1 •D
II placarding(example:placards will be displayed on the vehicle). ,Zmt
CARRIER NAME Z
r\'oatr� n Not TO Scale - ADDRESS 0
\ S1 on.. 0
• �\ g
CITY/STATE/ZIP 5
\ - MOTOR CARR.ID 0 Interstate 0 Intrastate
I r ❑ Not in Comm./Govt. ❑ Not in Comm./Other
0
;------ --1 - USDOT NO. ILCC NO. m
XI
Source of above z
. xi
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 M
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
to
LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 0 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Blue Green
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE El 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: 9 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE