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HomeMy WebLinkAbout2025-00006051 ILLINOIS TRAFFIC CRASH REPORT sheet 1 Df 2 Sheets 01111101111 I01101100 0 110 �11111110 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003 08451 u, 1 U21 2 4 1 Ut 5 U2 1 U1 1 U2 1 U1 1 U2 1 2 10 U, 4 U2 3 .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 2 VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ElB Injury and/or Tow Due To Crash YR 202512025-00006051 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n W HIGHLAND AVE Elgin04:21 ® ❑ RELATED ' V 0 N 01 28 2025 12,— ❑YES IX]NO U1 _ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION MFT l MI N E S W MCCLURE AVE COUNTY PROPERTY ❑Y 21N DOORING ❑y #OF MOTOR NI SLOW 15 u) ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C) FOR DAMAGEDAREA(S) FRO T TOWED U1 Q NAME(LAST,FIRST,M) Richardson.James. E. mo /1 9 3 9 Oldsmobile CutIassJCieraJSU re1996 00-NONE 13-UNDER CARRIAGE DUE TO CRASH ❑ p ©1 12 - EN E 10 1 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 0 171 M 2 SYTM IN ENGAGE15-OTHER 4 ❑Y ®SNE❑UNK VEH. 0 AT CRASHD 0 99-UNKNOWN 9 16•TOP 3 `Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�6 �i COM VEH 0 Ea 1 0 I . ELGIN I L 60123 0 1 0 FIRST CONTACT 11 7_: __5 *Ilyes.See Sidebar U1 Z DX24358 IL 2025 REAR TELEPHONE IL D 0 1 G3WH52M2TF343491 Progressive ❑v ®N U2 m IS EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same 12630942 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y El 2 0 p; DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 Nov 0 KCV 0 Dv !2 Yr 0 0 8 Chevrolet Traverse 2019 00-NONE al t2 c, 2 FIRE O CRASH 0 ® U2 2 C o 13-UNDER CARRIAGE c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 X ❑Y Ni N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraclion Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S-it 6 11:, 4 COM VEH ❑ ® U1 W FIRST CONTACT 11 7�_,__5 •(ryes.See Sidebar SOUTH ELGIN0Z IL 60177 0 1 0 DT19346 IL 2025 D IL D 0 1GNEVKKW5KJ255705 State Farm ❑Y ®N RDEF M EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 = 99 9 Gaspar-Jose.Saturnino 2129543SFP13 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = )UNIT) fSEATI (DOB! (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME(1(A.DDRESS)!(TELEPHONE! (EMS) (HOSPITAL) 2 5 08 / :A / / UI 1 D / / 3 0 EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 4 01 ,28 l2025 04 21 ®PM in a Work Zone? ®N DIRP 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 � o" 2 28 99 , , ❑PM• ❑Construction * 4 R 3 ❑ $I CITATIONS ISSUED El PENDING PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 o ® 11 4 ARREST NAME Richardson.James. E. 11-601-Ax 1515-000555 / / ❑PM SLMT o N • ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility r 2 ❑ 30 ARREST NAMEAM 7 / / ❑❑PM ❑Unknown work zone type U1 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 30 1515-BellEck.Stacy 601 03 ,04,2025 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 ADDITIONAL UNITS FORMS. r r----r••--, , I i A CMV is defined as any motor vehicle used to transport passengers or property and: r N combination):or more than pounds(example:truck or truck/trailer 0 -< 1. Has a weight rating10 000 INDICATE NORTH I Not To Scale I _ BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C r (example:shuttle or charter bus):or C) r r X I- I- -I- 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier O } } } transporting employees In the course of their employment(example:employee III L -----}----; � I - I. } } •transporter. sed or des gnated to transport between 9 and passengers,15r including the driver, c0 C for direct compensation(example:large van used for specific purose):or O L L____a____. :. L 5. Is any vehicle used to transport an hazardous material(HAZMAT)thatrequires placarding(example:placards will be displayed on the vehicle). m 0 iv '.' CARRIER NAME Z _ ADDRESS D to C) CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate 0 Intrastate 1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other ; _Y_ __1 USDOT NO. ILCC NO. m 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 VIM 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 Beige Black u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ElNOT DISABLING DAMAGE DAMAGE EXTENT 1 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