HomeMy WebLinkAbout2025-00006166 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 101101100 lll fl 0100
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0G3713056
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INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00006166 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 5 11
7 N CRANKING ST Elgin08:01
® ❑ RELATED ❑Y ®N 01 29 2025 ®AM ❑YES El NO U1 —<
g PRIVATE mo /day/yr ❑PM FLOW CONDITION IT1
_
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 1 (n
❑ FT/MI NESW Kane HIT&RUN ❑V ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS O
Q83 DRIVER t] PARKED ❑DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 NW 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
06 /
yr
13-UNDER CARRIAGE 10 i 12 2 FIRE 0 IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 2 m
F 2 4 Y SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 9 ALGN =
❑ ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEARF. POINT OF $ i� B �r.4 COM VEH El 0 1 n
V. Bloomingdale IL 60108 0 1 0 103890SB IL 2025 FIRST CONTACT 5 T_:REAR
_Q =II Yes.See Sidebar Ut
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TELEPHONE
IL B 7 4DRBUC8N2MB321140 Alliant Insurance ❑Y igi N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 School District U-46. U46 P41001458242501 1 r
"o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
7 0
❑ DRIVER X. PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 NMV 0 Ncv 0 DV
yr Volkswagen Jetta 2008 00-NONE 1i_ 12" DUE TO CRASH ❑ ® 1
o 13-UNDER CARRIAGE 9 O( 2 FIRE ❑ El U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 916-TOP 3 ❑ ® SPDR n
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value U1 0 -
POINT OF 8-.;, -4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 1 O T . it5 •COMI s.See SidebarEH ® CO
H DS87187 IL 2024 I 0 N
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
3VWRJ71 K88M115092 unknown ❑Y ❑N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
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HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP 996 <
RESPONDER
Y°0N U1 =
?UNIT) (SEAT) (008) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)?(ADDRESS)r(TELEPHONEI (EMS) (HOSPITAL)
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 18 3 co
01 r 29 r2025 08 01 ®❑PM AM in a Work Zone? ®N DIRP D
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
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2 ❑ 20 18 1 r ❑PM ❑Construction *
1
R 3 ❑ I!!I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
a1 ® 11 3 ARREST NAME Elms. Evette.J. 11-708 W0486-184 / ! ❑PM SLMT
o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
25
t 2 ❑ ARREST NAME AM
7 r r ❑❑PM ❑Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ ❑AM Workers present? ❑Y 25
486-Munoz.Jasmine 301 272-Bajak 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 -<
` ` -'- ' r INDICATE NORTH combination):or -I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
tiIkacumaym _ (example:shuttle or charter bus):or C
ef
L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier O
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. transporting employees in the course of their employment(example:employee
s � � transporter-usually a van type vehicle or passenger car).or w
L L.__-a-_ 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including C} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or o
71
L — — — — — — L i � t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
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placarding(example:placards will be displayed on the vehicle). XI
�. I e A CARRIER NAME School District U-46. U46 Z
1 N ADDRESS 355 E CHICAGO ST D
I Not To scale l
CITY/STATE/ZIP ELGIN!ILl60120 L
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
I I T I 0 Not in Comm./Govt. 0 Not in Comm./Other
--- --1 - USDOT NO. 0450046 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 ® 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?El❑ Yes II No 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 ®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
Yellow Gray
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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE