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HomeMy WebLinkAbout2025-00005302 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Of 2 Sheets 01111101111 I01101100 0 OlD 111110 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003 056 4* u1 1 U21 3 4 1 U1 3 U2 1 U1 1 U2 1 U1 1 U2 1 4 10 U, 1 U2 -3-1 .P0119* 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 14 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash El AMENDED YR 2025I 2025-00005302 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I S MCLEAN BLVD Elgin11:10 ® ❑ RELATED ®Y 0 N 01 24 2025 ❑AM ❑YES ®NO U1 -< _ _ PRIVATE mo !day/yr ®PM FLOW CONDITION MFT!MI N E S W BOWES RD COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 2 fA ❑ Cook HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ® FREE FLOW # LNS 0 Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EDUES 0 NIA/ 0 Ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 00 0 Mustard.Christo her.J. Ford Escape 2017 00-NONE DUE TOCRASH ® ❑ NAME(LAST,FIRST,M) p mo yr 13-UNDER CARRIAGE ©,I 0,:O 2FIRE ❑ tz STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL)THERDISTRACTED ❑ l4 U2 00 M M 2 SYTM 5 ❑Y ®SNE❑UNK VEH. 0 AT CRASH 0 15-99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN - r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s,;i�6 4 COM VEH 0 El 1 0 ~ St.Charles I L 60174 0 1 0 FIRST CONTACT 12 7 ; _5 *II Yes.See Sidebar U1 Z DU34476 IL 2024 E TELEPHONE IL D 0 1 FMCUOGD6HUD08512 Country Financial ❑Y ®N U2 m .5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Mustard. Michael P12A3339169 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y 0 N 2 ou m E{ DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑ !1 9 8 2 Ford F150 2017 00-NONE O, Oj-_, DUE TO CRASH rg ❑ 2 0 13-UNDER CARRIAGE FIRE 0 ® U2 C c F 2 6SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X 0 Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s 1 I 4 FIRST CONTACT 10 Y . B COM VEH ❑ ® Ut CO .5 •IfYes,See Sidebar C = Hanover Park IL 60133 0 1 0 69116SB IL 2024 I 0 Si) IL D 0 1 FTEW1 EP3HKD15522 Progressive Northern Insu ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 = BALLENO. ROCIO 976162486 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (DOB! (SEX) {SAFT) (AIR) (INJI ,(EJCT( (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE! (EMS) (HOSPITAL) 1 3 10 / 7/ / / 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 l2025 11 19 ®PM AM in a Work Zone? ®N DIRP D co 1 T PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 v 2 0 25 99 01,24 ,2025 11 16 ®PM El Construction >F " 3 ❑ zi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 2 J ❑AM 0 Maintenance U2 o El 11 4 ARREST NAME Mustard.Christopher.J. 11-601-Ax 467-394 01,24/2025 11 19 ®pM• ❑Utility SLMT I$!CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM o T 2 El ARREST NAME Mustard.Christopher.J. 11-305-A 467-395 01 r 24 ,2025 11 50 ®PM 0 Unknown work zone type U1 35 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 0 Am Workers present? ❑Y 35 467-Bankc. Hannah 701 391-Jacobucci 02 , 11 ,2025 01 30 ®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 0 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 -< r }----r----, ' I I Not ToScale cae combina tion):or I - r INDICATE NORTH -1 IIII BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C - (example:shuttle or charter bus):or M I I r 3. is designed to carry15 or fewer passengers and operated a contract carrier O < <.__-A..-.� y y } } } transport) em to ee In thecoursee of their em ng p y pbym�ent(example:employee � � C I I I I transporter-usually a van type vehicle or passenger car):or co L L.___a.. 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y— — - } } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or 0 L t ii. , 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m BCWS$9Rd ? placarding(example:placards will be displayed on the vehicle). :t1 _ --- CARRIER NAME Z Z r _ __ ADDRESS �l I I~ I I V) I I I I CITY/STATE/ZIP g can ivd. MOTOR CARR.ID Interstate Intrastate I r sam I I I®I El Not in Comm./Govt. 0 Not in Comm./Other 00 USDOT NO. ILCC NO. C m XI Source of above z . • m 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 Black Silver u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. Arties/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE