Loading...
HomeMy WebLinkAbout2025-00006295 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I01101100 00 III 11000 110 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003712541 u, 1 U21 1 1 1 U1 2 U2 1 u, 1 1_12 1 U1 1 U2 1 1 10 u, 1 U2 4 *P 0119* 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 El$501-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and f or Tow Due To Crash YR 2025I 2025-000062955 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1 ® ❑ RELATED ®Y 0 N 01 29 2025 ❑AM YES ®NO U1 -< S LIBERTY ST Elgin04:25 _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m FT!MI N E S W MAY ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 1 (n ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLESOT, INVLD ❑ STOPPED U2 —I El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n 0 6 / yr 13-UNDER CARRIAGE ©i ! FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) EN O 2 DISTRACTED 0 0 U2 2 m F 2 SY4 ❑Y ®SNE❑UNK VEH. 0 AT CRASH M IN D 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, it 6 1i COM VEH 0 Ea 1 n f. FIRST CONTACT 11 7__ --_;__S *IIYes.See Sidebar U1 0 Z ST CHARLES IL 60175-7626 0 1 0 DR55030 IL 2025 REAR TELEPHONE IL D 1G1ZF57509F239572 ALLMERICA FINANCIAL ❑Y ®N U2 I-- in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same A1CJ73343400 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER en Refused 0 Y ❑ N 2 0 p; DRIVER ❑ PARKED 0 DRIVERLESS ❑ PEO 0 PEDAL ❑EWES 0 uv 0 e v 0 Dv yr 111 12 ` E FIRE 0 ® U2 C o 13-UNDER CARRIAGE c F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOPO3 * X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN 0istraellon Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s-.;, 6 j( 4 COM VEH ❑ ® u1 CO FIRST CONTACT 3 7-'_, _S •(ryes,See Sidebar = ELGIN IL 60120 0 1 FB55188 IL 2025REAR n IL D 2HGES16503H615142 Progressive ❑Y ®N RDEF71 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Same 955837907 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPOND O N ui = KNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJ) (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 11 1 01 (29 (2025 04 26 ®PM in a Work Zone? ®N DIRP co 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 0 2 04 99 / ( 0 PM ❑Construction * Z 3 0 xi CITATIONS ISSUED El PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 a ® 11 1 ARREST NAME Rux. Peyton. M. 11-1101-A 1535000150 / i El PM SLMT o N 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility AM r 2 0 ARREST NAME 01(29 (2025 ❑❑PM 0 Unknown work zone type U1 25 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 25 1535-Solis, Laura 401 02 ,25(2025 01 30 0 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. A CMV is defined asmotor vehicle used to transportand: r ----,5-••--, ; any passengers or property Z 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< } i.-- -i-- --; } } } r -, , ; ; , ; ( INDICATE NORTH combination):or —I 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 3. Is . L.___A_. 1 i. ..._- - J transporting edmployeeslIn5 hecourseeo theire rsmployment exam pal e:employeener 73} } } transporter-usually a van type vehicle or passenger car):or co I- <.__-a-_-_-I , l• I- I- <--_-a-___� , , , , 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or 0 L L___-a____.: L L L i.___-..i.____� t i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires III placarding(example:placards will be displayed on the vehicle). XI --I CARRIER NAME Z i. ADDRESS 0 T. CITY/STATE/ZIP MOTOR CARR.ID 0 Interstate ❑ Intrastate 0 ❑ Not in Comm./Govt. ❑ Not in Comm./Other O USDOT NO. ILCC NO. m XI Source of above z . If Yes,Name on placard 0 4 digit UN NO. 1 digit Hazard class No. Xl Xl 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 v TRAILER WIDTH(S) 0-96" 97-102" >102' m TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Green.Light Silver u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 2 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