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HomeMy WebLinkAbout2025-00005158 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 I01101100 111 IMO 1 1111 111111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X(03{05a82 u, 1 U21 2 4 1 U, 2 U2 1 U, 1 1_12 1 U, 1 U2 1 1 15 U1 1 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash El AMENDED YR 202512025-00005158 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 71 ALFT LN Elgin 01:07 ® ❑ RELATED ®Y 0 N 01 24 2025 ❑AM YES ®NO U1 -< g PRIVATE mo /day!yr ®PM FLOW CONDITION IT1 _ FT!MI N E S W CAPITAL ST COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 1 0)0 Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C) FOR DAMAGEDAREA(S) FRCPtf TOWED U1 Q NAME(LAST,FIRST,M) mo /1 9 5 3 Nissan Altima 2002 00-NONE ©, Q i" , DUE TOCRASH ® ❑ 13-UNDER CARRIAGE } FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) OD 2 F 2 4 SYSTEM IN O ENGAGED 0 15-OTHER O9 16-TOP 3 DISTRACTED 0 0 U2 2 = ❑Y (Z/N ElUNK VEH. .ATCRASH 99-UNKNOWN `Distraction Value 9 ALGN r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 iI 6 4 COM VEH 0 0 1 0 m F. 0 1 0 FIRST CONTACT 10 7 ; _5 *IIYes.See Sidebar U1 Z SNU195 IL 2025 REAR TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 11/ 6 ( 0 1 N4BL4CV9NN329228 STATE FARM ®Y ❑N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same 0419497SFP13 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER en Refused 0 Y ❑ N 2 0 p; DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 New 0 Nev 0 Dv CIRCLE NUMBER(S) U1 !2 0 0 5 Hyundai Sonata 2013 00-NONE O Q�-O DUE TO CRASH ❑ 2 0 13-UNDER CARRIAGE 10( I 2 FIRE ❑ ® U2 C c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X ❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6-..,�.I,_4 COM VEH ❑ ® U1 CO FIRST CONTACT 12 7 1.5 •If Yes.See Sidebar H ELGIN IL 60120 0 1 0 EK90647 IL 2025 I 0 C M IL Other 0 SNPDH4AE2DH179629 American Alliance ❑Y ®N RDEF71 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Same I LAA-0996570-00 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 < Refused RESPOND O N U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 1 2 03 / M 2 4 0 1 0 m / / #OCCS D / / UI 2 D / / 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 4 01 ,24 ,2025 01 07 ®PM in a Work Zone? ®N DIRP co 1 t PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 1 C) T 2 0 2 23 ! , ❑PM ❑Construction 0 4 R 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM 0 Maintenance U2 o 1 ® 11 4 ARREST NAME Schiller, Debrah,J. 11-901-A 1543000058 / / ID Pm SLMT I$[CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME N El AM ,_,Utility o r 2 El ARREST NAME Schiller, Debrah,J. 3-707 1543000057 01!24 ,2025 02 00 0 PM 0 Unknown work zone type U1 30 2 2 3 ID OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME 0 AM Workers present? ❑Y 30 1543-Sturgeon, Kyle 900 275-Engelke 02 ,25,2025 01 30 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 ----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-_--; - I. INDICATE NORTH combination):or Li 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 1 I l�' r 3. Is desgned to carry15 or fewer passengers and operated a contract carrier 0 I- I- -A----1 o /4 ��7�. } } } transporting employee In the course of their employment(example:employee transporter-usually a van type vehicle or passenger car):or w L L.___a__._� 4. Is used ordesi natedtotrans rt between 9 and 15passengers,includingthedriver, Mimi Qp? } } for direct compensation(example:large van used for speific purose):or L L--_-a-...i. - - - I �� - - t i i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 71 O placarding(example:placards will be displayed on the vehicle). ,Zm ill placarding I r . 1 I CARRIER NAME D N rn I CITY/STATADDRESSEJZIP r , Not To Scale 5 I MOTOR CARR.ID 0 Interstate ❑ Intrastate 1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other ‘I. - --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. 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 ❑ 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 co 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 Gray Black u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO. _Other/Owners Residence SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE