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HomeMy WebLinkAbout2025-00006323 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100 Ilio 11111 Oil DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XO03712539- u, 1 U21 1 1 1 U116 U2 1 U, 1 1_12 1 U, 1 U2 1 5 11 u1 1 u2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ❑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 1 VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT) El B Injury and f or Tow Due To Crash El AMENDED YR 2O25I 2025-00006323 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 "I BOWES RD Elgin ® ❑ RELATED ❑Y ®N 01 29 2025 DAM ❑YES ®NO U1 -< PRIVATE mo /day/yr 05:56 ®PM FLOW CONDITION m 01 O�r MI NOS W North Randall Rd COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 15 cn Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 183 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 04 n T TOWED U1 0 Connor.Shirley. . Dodge Caliber 2007 00-NONE 2 0 DUE TO CRASH ® ❑ NAME(LAST,FIRST,M) y mo yr 13-UNDER CARRIAGE ©,I :: FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ Ea U2 04 M F 2 4 ❑Y ®SNEM❑ n is-OTHER UNK VEH. AT CRASHIN n ENGAGED 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S, i1 6 4 COM VEH ❑ Ea 1 0 " �- SOUTH ELGIN N I L 60177 C 1 0 FIRST CONTACT 12 7 ; _5 *II Yes.See Sidebar U1 ZPG P755 I L 2025 ' E TELEPHONE IL D 0 1 B3HB48B27D561217 State Farm ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m South Elgin Fire 99 9 Same 2449969-SFP-13 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER 1 9 6 2 Toyota RAV4 2017 00-NONE 'o,� t2 c,�2 FIRE DUE OCRASH 0 ® U2 2 C o —yr . 13-UNDER CARRIAGE Ti F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X ❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value 9 g N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 1 at t. 4 COM VEH D ® U1 IN FIRST CONTACT 6 O7 ,�= )OS •If Yes,See Sidebar C Z South Elgin IL 60177 0 1 0 AD26091 IL 2025 I AR 0 Si) n IL D 0 2T3BFREV6HW693745 State Farm ❑Y ®N RDEF M EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 = Elgin Fire 99 9 Same 1703587-SFP-13 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 < Provena St.Joseph RESPONDER U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (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 05 56 ®AM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C) v 2 0 28 18 01,29 ,2025 06 04 ®PM El Construction * R 3 0 ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 z J ❑AM 0 Maintenance U2 a 1El 11 1 ARREST NAME 0 Connor.Shirley.A. 11-601-Ax S1509000135 01,29 r2025 06 09 ®PM SLMT - o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility 0 AM t 2 ElARREST NAME 01 r 29 12025 06 48 ®PM 0 Unknown work zone type U1 45 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 45 1509-Wortman.Cassie 702 312-Rigano 02 , 18,2025 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••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z birati rating more than 10,000pound (example:truck or truckrtrarler } }--- I- -- ; .t:l o , Itl comnatio :weight -I T INDICATE NORTH p1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C I I I namso•.j - } r r r (example:shuttle or charter bus):or 0 I- L.___A.._.� 3. Isdesgnedto carry 15or fewer passengers and operated bya 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 co L ,. 4. Is used or designated to transport between 9 and 15 passengers,including C}--- ----; - } } } g po passen rs,includi the driver, —«_ o- . . . for direct compensation(example:large van used for specific purpose):or O L L____a.....I -.a-�= l. I. 1 , 5. Is any vehicle used to transport anyhazardous material(HAZMAT)thatrequires m � r . , placarding(example:placards will be displayed on the vehicle). . D -`' ` CARRIER NAME —I Z / ADDRESS O / U' C) CITY/STATE/ZIP g r0 MOTOR CARR.ID 0 Interstate 0 Intrastate❑ I I . I ❑ Not in Comm./Govt. Not in Comm./Other , _Y_ _. USDOT NO. ILCC NO. m XI Source of above z . Were HAZMAT placards on vehicle? 0 Yes 0 No = If Yes,Name on placard O 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 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 Black Black u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO. _Redmons/Impound Lot Garage . 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