HomeMy WebLinkAbout2025-00006063 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
I01101100
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003713029'
u, 9 U21 3 4 1 U1 2 U2 1 u,99 u2 1 u,99 u2 1 4 10 u, 3 U2 1 *P 0119
INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY 0 5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S 0$501-51.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00006063 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 -n
NATIONAL ST El In 05:20
® ❑ RELATED ' V 0 N 01 28 2025 ❑AM ❑YES ®NO U1
_ -Cot
g PRIVATE mo /day/yr ®PM FLOW CONDITION M
FT!MI N E S W S STATE ST COUNTY PROPERTY ElY ® N DOORING ❑y #OF MOTOR 0 SLOW 1 cn
❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Qg)DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0
FOR DAMAGEDAREA(S) FROnf TOWED U1 O
NAME(LAST,FIRST.M)
Unknown. mo yr 0. / / Unknown Unknown 00-NONE 0O , OUETOCRASH ❑
EN
13-UNDER CARRIAGE ! FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) Oa. O
SYSTEM IN
9 ❑Y ❑N DUNK VEH. ENGAGED 15-OTHER 9 16.TOP 3 DISTRACTED 0 ]$I U2 4 <<T1
9AT CRASH 99-UNKNOWN `Distraction Value ALGN =
s 4 COM VEH ❑ j$J
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF I�6 �i,_5 U1 1 0
1 FIRST CONTACT 11 7_; _0 9 0 *If Yes.See Sidebar
2 Z ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 11/
a°, 99 ❑Y ❑N U2 R1
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 99 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
.IT, RESPONDER Y°®N
m
g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES 0 ivy 0 KCV ❑ CIRCLE NUMBER(S) U1
Dv
'1 9 9 5 Dodge Charger 2023 00-NONE „ " Oj-_, DUE TO CRASH ❑ 2
13-UNDER CARRIAGE I, FIRE 0 ® U2 C
c
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 016-TOP 3 X
❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistraglon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 0) ,.4 COM VEH ❑ ® tit CO
CONTACT 11 O j .�-5 •If Yes,See Sidebar C
ELGIN IL 60123 0 1 0 WNV500 SC 2025 REAR 0 Si)M
IL D 0 2C3CDXBG7PH546812 Continental Casualty Comp ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Avis Car Rental BUA 7001700830 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)!(TELEPHONE! (EMS) (HOSPITAL)
2 6 03 /
' D
/ / 4 O
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ID U2 Z
N 1 ® 11 1 01 /28 /2025 05 20 ®PM in a Work Zone? ®N DIRP co
1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 2 C)
T
O 1 2 ❑ 2 99 / / ❑PM• ❑Construction c
Z3 ❑ ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5
- u a, ARREST NAME / / ❑PM '
1 ® 0 Utility
1 1 1 0 CITATIONS ISSUED ❑PENDING SLMT
oSECTION CITATION NO. ROAD CLEARANCE TIME El AM
T 2 ❑ ARREST NAME 01/28 /2025 05 30 ®PM ❑Unknown work zone type U1 3O
, T
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y
2 2 3 ❑ El AM Workers present? ❑ 30
1528-Rivera. Kevin 701 - / / ❑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-----; S?State combination):or —I
St INDICATE NORTH p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- } (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
i. `�----:----i Unit. t National?St _ } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver. C
- ———— for direct compensation(example:large van used for specific purpose):or
D
_ _ i I 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
rn
placarding(example:placards will be displayed on the vehicle). ;p
�nit?#1 _----- D
Wnlntrt?Ave , CARRIER NAME
i
ADDRESS 0
w
C)
CITY/STATE/ZIP g
Not 7o scare 1 - MOTOR CARR.ID 0 Interstate 0 Intrastate
r ; ❑ Not in Comm./Govt. 0 Not in Comm./Other
-"-------1 - USDOT NO. ILCC NO. m
XI
Source of above z
. Form Number
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' -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