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HomeMy WebLinkAbout2025-00005132 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100 0 110101000 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003708460 u, 9 u21 3 4 1 U, 2 U2 1 u,99 u2 1 111 99 U2 99 5 11 U1 1 U2 1 *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 ®NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00005132 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 71 ® ❑ RELATED ❑Y ®N 01 23 2025 DAM ❑YES ®NO U1 ROUTE 20 Elgin08:15 _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m 5 !MI N E s Shales Pk COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 Co Egi2 ® © Cook HIT&RUN ®Y ❑ N WITH VEHICLESOT, INVLD ❑ STOPPED U2 --I 0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 18:DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV ❑ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 FOR DAMAGEDAREA(S) FRONT TOWED U1 0 NAME(LAST,FIRST,M) Unknown.O. mo / / yr Unknown Unknown 00-NONE ,1,_ O OI_1 DUE TOCRASH ❑ EN 13-UNDER CARRIAGE 10 ' 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 4 n<1 SYSTEM IN ENGAGED 15-OTHER 9 76.TOP 3 9 9 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s_iL 6 �i, COM VEH 0 Ea 1 I- FIRST CONTACT 12 7_;I 0 9 -5 *II Yes.See Sidebar U1 0 2 Z ' E TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1/ unknown 0 Y 0 N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m co 99 9 Same unknown 2 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER r D Y°N0 N m N DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑ ivy 0 Ncv ❑DV CIRCLE NUMBER(S) U1 !1 9 9 4 Ford Edge 2011 00-NONE 11"j t2..-_, DUE TO CRASH ❑ 2 x ... —Yr 13-UNDERCARRIAGE ta;l 2 FIRE ❑ ® U2 C c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP 3 ❑Y Ni N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value g g POINT OF s 4 COM VEH D ® Ut CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR ._,!1- 6 I'._ FIRST CONTACT 5 __Os _5 •IfYes.SeeSidebar BARTLETT IL 60103 0 1 BW78902 IL REAR 0 IL D 2FMDK3KC5BBA62124 Farmers ❑Y ®N RDEF P3 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X 99 9 Same 191891077 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPOND 0 N U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 11 9 01 r 24 l2025 11 30 ®❑PM AM in a Work Zone? ®N DIRP D 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 ❑ 18 18 N 3 ❑ ❑CITATIONS ISSUED 0 PENDING + ! ❑PM• ❑Construction SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 3 —a ARREST NAME / / ❑PM ' o, N ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility SLMT 59 r 2 ❑ ARREST NAME AM 7 1 1 ❑❑PM ❑Unknown work zone type U1 n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 D ❑AM Workers present? ❑Y 50 547 Homeier.William 275-Engelke , / ❑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 —I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C JIIIIII _ (example:shuttle or charter bus):or X L 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 -----}----; _. 1 i►� - I. } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver, e1whRPk�r 4+ 1'I T : . for direct compensation(example:large van used for specific purpose):or to L L____a____. I R_ _ t l. I I 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m Rg2o placarding(example:placards will be displayed on the vehicle). 11 —I CARRIER NAME Z _ ADDRESS w CITY/STATE/ZIP 0 g MOTOR CARR.ID 0 Interstate 0 Intrastate I I T 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' m TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 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 0 NOT DISABLING DAMAGE DAMAGE EXTENT 9 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