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HomeMy WebLinkAbout2025-00006737 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I01101100 11111 II 111 IIII IOil DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003712469 u, 1 U21 1 1 1 U1 7 U2 1 U, 1 1_12 1 U, 1 U2 1 1 11 U1 1 U2 1 *P 0 11 9* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY ❑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 51,500 El NOT ON SCENE(DESK REPORT) El AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00006737 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 :I RT20 WB El 03:45 ® ❑ RELATED ❑Y ®N 01 31 2025 12,— ❑YES ®NO U1 -< _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION ITI FT!MI N E S W S STATE ST COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR El SLOW 1 (/)❑ Kane HIT ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I El AT RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 NOV 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C) 0 7 / yr 13-UNDER CARRIAGE 10.I 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 2 (II M 2 4 SYTM❑Y ®SNEDUNK VEH. 0 ATCRASHD 0 99-U 15-UNKNOWN THER9 16•TOP 3 `Distraction Value 9 ALGN X. r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF iL 6 I,.4 COM VEH 0 g! 1 0 ~ ELGIN I L 60123 0 1 0 FIRST CONTACT 12 7_: __5 *lI Yes.See Sidebar U1 Z BN60099 IL 2025 REAR TELEPHONE IL D 0 SFNYF4H99DB043450 STATE FARM ❑Y ®N U2 Ill , m .5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same 1432106-SFP-13 2 r o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused 0 Y ® N 2 c m g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEOAL 0 EWES 0 /1 9 6 3 Kia Motors Colporento 2020' 00-NONE It-' 12..-_, DUETO CRASH ❑ !1 2 o Yr 13-UNDERCARRIAGE 10;1 2 FIRE 0 ® U2 C c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X ❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *OistracI Dn Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S iI all,,_4 COM VEH ❑ ® Ut CO FIRST CONTACT 6 Y__{_O ._5 •If Yes.See Sidebar 11'. FIRST IL 60120 0 1 0 J242287 IL 2025aR M IL B 7 5XYPG4A34LG641239 STATE FARM ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Same 1158290-SFP-13 BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 < Refused RESPONDER U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI 1(EJCT( (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) 1 1 01 / / / UI 2 :A 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 1 1/ , 1/ /025 03 40 0 pm in a Work Zone? ❑N DIRP co 1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 ,, O 2 0 03 28 / / 0 PM ®Construction * Z 3 0 xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 ❑AM 0 Maintenance U2 o1 ® 11 1 ARREST NAME Olvera.Javier 11-601-Ax W1541000096 / / El PM SLMT o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility t 2 ❑ ARREST NAME AM 7 / / pM El Unknown work zone type 45 U1 n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑Y 45 1541-Wilkerson.Tondeo 700 / / ❑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 -< c ` --I -' r INDICATE NORTH combination):or —I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C _ } (example:shuttle or charter bus):or ( ) 3. Is designed to}_ A i carry15 or fewer passengers and operated a contract carrier 0 --- ---" I } transporting employee �In the course of their employment(example:employee ms=D• UNIT 1—UNIT 2 transporter-usually a van type vehicle or passenger car):or 0 4. Is used or designated to transport between 9 and 15 passengers,including cC/t } } � • for direct compensation(example:large van used for cific ur mdudi the driver, Pe ( P 9 Pe purpose):or 0 L i t 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). XI 414 --________*_.....__: „,,r.,...,I CARRIER NAME Z ADDRESS 0 Not To Scale ] D rn C) CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate 0 Intrastate 1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other ‘I. - --1 - USDOT NO. 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 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 Silver White 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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO. DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE