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HomeMy WebLinkAbout2025-00006064 ILLINOIS TRAFFIC CRASH REPORT sheet 1 Df 2 Sheets 01111101111 I01101100 0 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003706750' u, 9 U21 3 4 1 U1 2 U2 1 u,99 u2 1 u,99 U2 1 3 11 u, 1 U211 �K P 0119 INVESTIGATING AGENCY DAMAGE TO ANY El$500 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) El AMENDED ElB Injury and for Tow Due To Crash YR 202512025-00006064 VENT ADDRESS NO. HIGHWAY or STREET NAME ® ❑CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 mRT20 RELATED ®Y 0 N 01 28 2025 05:23 ❑AM ❑YES ®No U1 -< Elgin PRIVATE mo /day/yr ®PM FLOW CONDITION m FT!MI N E S W LAMBERT LN COUNTY PROPERTY El ® N DOORING Ely #OF MOTOR IR SLOW 15 u) ❑ Cook HIT ®Y ❑ N WITH VEHICLES INVLD El STOPPED U2 --I CO AT RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 C) FOR DAMAGEDAREA(S) FRONT TOWED U1 0mo Unknown.0. Unknown Unknown 00-NONE ©, >2 �/OUETOCRASH ❑ EN NAME(LAST,FIRST,M) yr 13-UNDER CARRIAGE 10.I 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0U2 45 II n SYSTEM IN 9 9 ENGAGED OTHER 916-TOP 3 9 9 ❑Y IDN CO UNK VEH. 9 AT CRASH -UNKNOWN 6 4 `Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF i 6 'i C.OM VEH 0 E! 1 0 I.. FIRST CONTACT 12 7__:1___,__5 *lives.See Sidebar U1 0 9 0 UNKNOWN RE 2 Z _ TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 11/ 9 UNKNOWN Unknown ❑Y ®N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m co 99 9 Same Unknown 1 rn `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER r : Y OEN eM m g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES 0 �1 9 9 1 Dodge Journey 2015 00-NONE ,�_.i t2'-_, DUE TO CRASH ❑ 2 0 13-UNDER CARRIAGE 101 l 2 FIRE 0 ® U2 C c F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP 3 X ❑Y EQ N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistracllon Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF si 6 ....4 COM VEH ❑ ® U1 CO FIRST CONTACT 6 7 -�'OS •(ryes,See Sidebar C ELGIN IL 60123 0 1 0 BV43900 IL REAR 0 Si) IL 0 3C4PDDBG8FT544102 State Farm ❑y ISI N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Same 3337167 SFP-13 BAC $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER u1 = KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 1 01 ,28 �2025 05 23 ®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 0 28 03 N 1 3 ❑ ❑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 Utilit SLMT o u SECTION CITATION NO. ROAD CLEARANCE TIME Ely ❑CITATIONS ISSUED PENDING t 2 El ARREST NAME 01 128 12025 06 30 ®PM El Unknown work zone type U1 0 AM 45 n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ 485-Quintana.Josue 401 ❑AM Workers present? ❑N 05 1 ❑PM ® 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. r- - - _ , Z , Not To Scale 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer r }----r----, N ij I - r -< col. or INDICATE NORTH BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C _ m _ (example:shuttle or charter bus):or X A /.. }A 3. Is desgned 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 /"' 4. Is used or desi nated to trans rt between 9 and 15 ge ng N}-----}----; - } } } g po passen rs,includi [he driver, for direct compensation(example:large van used for specific purpose):or o L i t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires •p a t placarding(example:placards will be displayed on the vehicle). m E. —Unit 2 . . . . . CARRIER NAME Z tittt 1 ADDRESST. 0 CITY/STATE/ZIP 0 1 MOTOR CARR.ID 0 Interstate 0 Intrastate I I T I D"`'-s"i I I 0 Not in Comm./Govt. Not in Comm./Other 0 �I. ------- - USDOT NO. ILCC NO. <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 Red u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 9 TOWED BY/TO: _ SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO: DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE