HomeMy WebLinkAbout2025-00006692 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets Mill III H IIII
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 202512025-00006692 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 7
® ❑ RELATED ' V 0 N 01 31 2025 ®AM ❑YES ®NO U1
ST CHARLES ST Elgin11:51
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION IT1
FT!MI N E S W BENT ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD El STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
0 4 !
yr
Subaru XV Crosstrek 2.0 2019 00-NONE
13-UNDER CARRIAGE DUE TO CRASH ❑
Q Q, EN ' E
1 2 FIRE 0 lE
10 <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 r11
F 2 3 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 16.70P 3 _
❑N DUNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, i�B �i COM VEH ❑ Ea 1 00
F. FIRST CONTACT 1 7 ;—_;__5 *Irves.See Sidebar U1
V Z Schaumburg IL 60193 C 1 EE59275 IL 2025 REAR
TELEPHONE
IL D JF2GTAMC3KH358568 State Farm ❑Y ®N U2 10 , m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 1389107-SFP-13 2 r
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused El ElN 2 0
x DRIVER ❑ PARKED ❑DRIVERLESS 0 PED O PEDAL ❑EWES ❑iiuv 0 i v 0 Dv CIRCLE NUMBER(S) U1
'1 9 5 6 Toyota Camry 2009 00-NONE 0.. Qi'-0 DUE TO CRASH ❑ 2 73
o Yr 13-UNDER CARRIAGE 10( I 2 FIRE ❑ El U2 C
M 2 5 SYSTEM IN ENGAGED 15-OTHER 9,16-TOP 3 0 X
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistrac on Value
POINT OF 8 i1 1. 4 COM VEH ❑ ® U1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR s
FIRST CONTACT 11 7 _, _5 •If Yes.See Sidebar
= BARTLETT IL 60103 C 1 AE59257 IL 2025 I 0
IL D 4T4BE46K29R049993 Travelers ❑Y ®N RDEF Xl
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Same 606325497 203 1 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPOND ON U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
2 3 09 / F 2 5 0 1 U2 996 m
/ / #OCCS >
/ / U1 1 D
/ / 2 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 4 City of Elgin stop sign post 01 ,31 /2025 09 00 ®❑pM 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
v 2 ❑ 150 DEXTER CT ELGIN IL 60120 2 99 / / ❑AM ❑Construction >E
Z 3 0 El CITATIONS ISSUED ElPENDING SECTION CITATION NO. EMS ARRIVED TIME ❑
❑AM Maintenance U2 5
1 ® 11 4 ARREST NAME Tokarz. Patricia. M. 11-901 414-1001 / / ID PM SLMT
o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑ 30
Utility
r 2ARREST NAME AM
7 El / r ❑❑PM El Unknown work zone type U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM ❑Y 30
414-Lara. Saul 401 368-Davenport 02 / 18,2025 09 00 ❑PM Workers present? ®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- }-- -'-- --' A INDICATE NORTH combination):or -I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
. 9 sP n
- r r ,. (example:shuttle or charter bus):or
Not To Scale 3. Is designed to carry15 or fewer passengers and operated a contract carrier O
} A i `
} } } transporting employee In the course of their employment(example:employee
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transporter-usually a van type vehicle or passenger car).or W
L 4. Is used or designated to transport between 9 and 15 passengers,includingN
--- ----+ - } } } g Po the driver,
. for direct compensation(example:large van used for specific purpose):or
NE llMO
i. < i. • 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). ;p
_ - - Z
r . .. L. 1..- CARRIER NAME Z
ADDRESS 'n
O
CITY/STATE/ZIP C)
MOTOR CARR.ID 0 Interstate ❑ Intrastate
I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other
----------1 USDOT NO. ILCC NO. m
XI
Source of above z
. MCS 0 Yes 0 No 0 Unknown Out of Service 0 Yes ❑No 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
Red Silver
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 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE