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HomeMy WebLinkAbout2025-00006908 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100 1111 IIIHO11000 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003713046 u, 9 u21 3 4 1 U, 1 U2 1 U199 u2 1 U,99 U2 1 1 11 U1 1 U211 *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 3 VEHICLE/PROPERTY ®OVER$1,500 ®NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00006908 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 71 LARKIN Elgin ® ❑ RELATED ❑Y ®N 02 01 2025 ❑AM ❑YES ®NO U1 -< PRIVATE mo /day/yr 12:10 ®PM FLOW CONDITION M _ COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 u) I2;15 ®/MI N E S © Airlite Ave WITH VEHICLES INVLD ❑ STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN I2J Y ElN PEDALCYCLIST IZI N ® FREE FLOW # LNS 0 (8:DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 / / FOR DAMAGEDAREA(S) FRO T TOWED U1 0 Unknown.O. Unknown Unknown 00-NONE EN „ 12 , OUETOCRASH 0 NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE CR 101 ! 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 14 U2 1 M SYSTEM IN ENGAGED 15-OTHER 9 t6.TOP 3 9 9 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN = s 4 COM VEH 0 Ej r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR0 I- POINT OF _,I�6 �i,_5 *If Yes.See Sidebar Ut 1 0 0 9 FIRST CONTACT 12 7i mai - 2 Z ' E TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 4 D I— unknown ❑Y ❑N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same unknown 1 rn `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ❑ N 99 0 �{ DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 row 0 NCv 0 Dv /1 9 5 9 Chevrolet Equinox 2020' 00-NONE ,�_"j 12 -_, DUE TO CRASH ❑ (� 273 0 13-UNDER CARRIAGE to l 2 FIRE El El U2 C F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP 3 X ❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistrac on VaIue 9 g N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 iI- 6 �' 4 COM VEH ❑ ® U1 CO _ FIRST CONTACT 6 Y__{_O ._5 • H Hampshire I L 60140 0 1 HY8531 I L 2025 REAR 0IfYes.See Sidebar N IL D 0 3GNAXSEV3LS585533 State Farm ❑Y ®N RDEF X EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Muncy.Thomas.W. 0459467SFP13 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (D051 (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME(1(A.DDRESS)/(TELEPHONE) (EMS) (HOSPITAL) 2 6 09 / ' D / / 3 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 11 9 02/01 /2025 02 00 ®PM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 30 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 2 0 18 18 N 3 ❑ ❑CITATIONS ISSUED 0 PENDING • + / ❑PM• ❑Construction SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 3 -a, ARREST NAME / / ❑PM ' o u ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT 45 r 2 0 ARREST NAME AM 7 / / ❑❑PM ❑Unknown work zone type U1 n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ ❑AM Workers present? 0 Y 45 547 Homeler.William 272-Bajak / / ❑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•---, , Q•N A CMV is defined as any motor vehicle used to transport passengers or property and: ___ ___-1 Not To Scale 1 1. Has a weight rating more than 10,000 pounds(example:truck or truck/trailer c • --I- 1 I. INDICATE NORTH comWrtation)or p0 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C - } (example:shuttle or charter bus):or X L L---------_-I I transporting3. Is gemployeened to s 5 or fewer inhecourseeo their rs employ nt example:employee a contract ner 73 } r } transportr-usually a van type vehicle or passenger car):or w I. L.___a__ I "100"e` I 7 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct com nation exam I lar a van used for s �cifice ur o ):or the driver, Pe ( P 9 Pe P pos�):or ' L.___a____. - t i i _ 5. Is anyvehicle used to transport anyhazardous material(HAZMA that requires - u„rir R\ — placardig(example:placards will be isplayed on the vehicle). m 0 .-1 * Z i' lr r -1- 1 { . , L ,..._ CARRIER NAME Z ADDRESS rn 0 CITY/STATE/ZIP g - MOTOR CARR.ID 0 Interstate 0 Intrastate I I T I I 0 Not in Comm./Govt. Not in Comm./Other ❑ 0 I. -- . ._; USDOT NO. ILCC NO. rn Source of above z . 0 Yes II No ❑ Unknown A 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 Gray u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 9 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