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HomeMy WebLinkAbout2025-00005462 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100 0 liii 001 000 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003706738 u, 9 U2 1 1 1 U199 u2 U199 1_12 U, 1 U2 5 6 u, 1 U2 *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 El$501-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash 0 AMENDED YR 202512025-00005462 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1 SHALES PKWY El In06:46 ® ❑ RELATED ❑Y ®N 01 25 2025 DAM ❑YES IX]NO U1 -< g PRIVATE mo !day/yr ®PM FLOW CONDITION m 10 !MI N E S W Chaparral Cir COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW Cl) ® O pCook HIT&RUN ®Y ❑ N WITH VEHICLESOT, INVLD DO STOPPED U2 -I O AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 (g:DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0 icy 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) y N 2 0 / ! FOR DAMAGEDAREA(S) FROM�TOWED U1 0 Unknown Hyundai Kona 2022 00-NONE ©, >2 �/DUE TOCRASH ❑ EN NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 16 1 • 2 FIRE ❑ NIC STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED U2 2 5 SYSTEM IN Y 0 ENGAGED 0 15-OTHER 9t6.70P 3 0 _ ❑ ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 9 ALGN r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S,;ii_6 1,.4 COM VEH 0 )g! 3 00 ~ B 1 0 FIRST CONTACT 12 7 ; __6 *II Yes.See&debar U1 Z DL13812 IL 2025 REAR TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED KM8K62AB2NU904947 State Farm ❑Y ®N U2 r- 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m a Siripanya. Rithideth 0616959SFP13 1 r `5 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER r D Y JN 73 0 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0,uv 0 Ncv 0 Dv yr ,2 - C o 13-UNDER CARRIAGE 10 I c. 2 FIRE ❑ 0 U2 C c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP 3 ❑ 0 SPDR 0 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value U1 9 - POINT OF &-.;, 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT Y�='+:=6 C•IO e1sYEH See •Sidebar❑ 0 C CO F` REAR` C M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O ❑Y ❑N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = BAC HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < RESP❑YDNDER❑N U1 = (UNIT) (SEATI (008) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0 / / U2 r m 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 43 3 City of Elgin light pole 01 ,25 /2025 06 46 ®AM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 � v t 2 ❑ 150 DEXTER CT ELGIN IL 60120 99 99 ! ! 0 PM ❑Construction * Z3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 -a, ARREST NAME / / ❑PM ' o u • ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility SLMT 30 t 2 ARREST NAME AM ! r ❑❑PM ❑Unknown work zone type U1 El 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y 2 3 ❑ - El Am Workers present? 0 1530 Soto.Oscar 102 ! ! ❑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 Shales?Pkwy ADDITIONAL UNITS FORMS. 0 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 truckrtrailer -< c ` --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 , do , 3. Is designed to carry15 or fewer passengers and operated a contract carrier I O -- r } } } transporting employee in the course of their employment(example:employee X transporter-usually a van type vehicle or passenger car):or w 4. Is used or designated to transport between 9 and 15 passengers,including (I) CIO } } } g po passen rs,includi the driver, . for direct compensation(example:large van used for specific purpose):or O Not To Scale 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires III placarding(example:placards will be displayed on the vehicle). ,Zmt —I CARRIER NAME Z ADDRESS 0 T. CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate ❑ Intrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other ----'Y----1 - USDOT NO. ILCC NO. rn XI Source of above Z . ❑ Yes 0 No 0 Unknown g D Did Carrier Safety Regulations MCS)violation contribute to the crash? A ❑ Yes No ❑ 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'; 0 Yes 0 No 2 TRAILER VIN 1 m co LOCAL USE ONLY TRAILER VIN 2 m v TRAILER WIDTH(S) 0-96" 97-102" >102' m TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 o u 1 COLOR U_COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Gray u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO: _Redmons . SELECT CODES FROM THE BACK OF CRASH BOOKLET U_TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO.DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE