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HomeMy WebLinkAbout2025-00005818 ILLINOIS TRAFFIC CRASH REPORT sheet 1 Df 2 Sheets 01111101111 I01101100 0 liii 11101 10 I DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003706784+ u, 1 U21 1 1 1 Ut ' U2 1 U1 1 U2 1 U, 1 U2 1 3 12 U, 18 U2 1 *P 0119 INVESTIGATING AGENCY DAMAGE TO ANY 0 5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00005818 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 71 ® ❑ RELATED PRIVATE ❑Y ®N 01 27 2025 12,—AM ❑YES ®NO U1 -< RT20 WB Elgin mo /day/yr 04:53 ®PM FLOW CONDITION m • 02040!MI N E S © LIBERTY St COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 15 u) Cook HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ® FREE FLOW # LNS 0 (i DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EDUCE ❑uuv ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n / / FOR DAMAGEDAREA(S) FROM NAME(LAST,FIRST,M) Johnson. Hakeim. E. mo Chevrolet Silverado 00-NONE DUE TO CRASH ❑ VI IE yr 2017 ® 12 NT TOWED U1 Q 13-UNDER CARRIAGE 10 1 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m M 2 SYTM IN ENGAGE15-OTHER 4 ❑Y ®SNE❑UNK VEH. 0 ATCRASHD 0 99-UNKNOWN 9 16•TOP 3 `Distraction Value 9 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�a �i 4 COM VEH ❑ j$J 1 0 Hillside IL 60162 0 1 0 FIRST CONTACT 11 7_: __5 *Ilyes.SeeSidebar U1 Z 3812844B IL 2025 REAR TELEPHONE IL D 0 1 GCVKREH7HZ406707 GEICO ❑Y ®N U2 I-- 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m co Same 6185297782 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER en Refused ❑Y ® N 2 0 p; DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑NMv 0 NCV ❑DV CIRCLE NUMBER(S) U1 1 9 6 7 Cadillac SRX 2016 00-NONE 'o,� t2 c,�2 FIRE DUE oCRASH ® U2 2 C o 13-UNDER CARRIAGE El c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X ❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istract Dn Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 1 6 .t. 4 COM VEH D ® Ut CO F,,, FIRST CONTACT 5 O7 ,�=Q!OS C.IfYes.See Sidebar C ELGIN IL 60123 0 1 0 BL49002 IL 2025 FIRST Si)0 M IL D 0 3GYFNEE30GS573313 STATE FARM ❑y ®N RDEF71 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 = Sanchez. Benito 2042777SFP13 BAG $ 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)1ITELEPHONE) (EMS) (HOSPITAL) U2 996 r m ##occs y 71 / ,, U1 1 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 1 01 ,27 �2025 04 53 ®pm in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 2 ❑ 28 03 N 1 3 ❑ 0 CITATIONS ISSUED 0 PENDING + ) _ ❑PM• ❑Construction SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 3 -a, ARREST NAME / / El PM ' 1 ® 1 1 1 UtilitySLMT o NSECTION CITATION NO. ROAD CLEARANCE TIME ❑ 0CITATIONS ISSUED PENDING t 2 El ARREST NAME 01 127 12025 04 53 ®PM El Unknown work zone type U1 0 AM 55 % -r OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ ❑AM Workers present? ❑Y 55 456-Romalo.Carmine 401 - r r ❑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 .Z-1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C - } (example:shuttle or charter bus):or X . A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O } } } transporting employees in the course of their employment(example:employee X transporter-usually a van type vehicle or passenger car):or w L L.___a____� � e - . I. I- 1 4. Is used or designated to transport between 9 and 15 passengers,including the driver. N frea t r for direct compensation(example:large van used for specific purpose):or O L -a-_ - � i i I ._ 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires 'D m placarding(example:placards will be displayed on the vehicle). ----unn2— XI -- CARRIER NAME —I ROUTE92O?W/B4WEBT7OF?LIBERTY - ADDRESS D Not 7b Scab (n CITY/STATE/ZIP 00 MOTOR CARR.ID 0 Interstate 0 Intrastate I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other -"--------1 - USDOT NO. ILCC NO. rn XI Source of above 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 v TRAILER WIDTH(S) 0-96" 97-102" >102' T TRAILER 1 ❑ ❑ 0 Z TRAILER 2 0 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: 1 TOWED BY/TO: _ . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE