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HomeMy WebLinkAbout2025-00007010 ILLINOIS TRAFFIC CRASH REPORT sheet 1 Of 4 Sheets 01111101111 101101100 II III 0 0000 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003712450 u, 2 U2 1 1 1 U145 u2 u, 1 1_12 U, 1 U2 1 5 9 u, 1 U221 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El 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 2 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash El AMENDED YR 2025I 2025-0000701 O VEHT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 71 1158 DUNCAN AVE El In01:47 ® ❑ RELATED ❑Y ®N 02 02 2025 ®AM ❑YES ®NO U1 -< _ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 2 fA ❑ FT!MI N E S W Kane HIT&RUN ❑Y ® N WITH VEHICLESOT, INVLD ❑ STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Q83 DRIVER O PARKED El DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIA/ 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 02 n FOR DAMAGEDAREA(S) FROM TOWED U1 Mills. Nicholas. R. 0 3 / yr O3-UNDER CARRIAGE al ©,I O, FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 0 U2 02 m M 2 SY 15-OTHER 4 ❑Y ®SNE❑UNK VEH. O AT CRASM IN H O 99-UNKNOWN 9 ,6•TOP 3 `Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s,. --it B �i COM VEH 0 ZgJ 1 0 F. FIRST CONTACT 1 7 _;__5 *If Yes.See Sidebar U1 Z Carpentersville IL 0 1 0 BV75813 IL 2025 Is TELEPHONE IL D 0 1C4NJ PBBOG D803081 Progressive ❑Y ISIN U2 I— i n EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 Same 913262815 1 r "o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER XI Refused ❑Y ® N 2 0 p DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMV 0 NOV 0 DV yr _ 13-UNDER CARRIAGE 101 t2 ;,_2 FIRE ❑ ® U2 C Ti SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED `a SYSTEM IN 0 ENGAGED 0 15-OTHER O16.70P 3 ❑ ® SPDR n ❑Y ®N DUNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF O I 4 COM VEH ❑ ® Lit CO F,,, FIRST CONTACT 7 Q � .s •It Yes.See Sidebar C 3610450B IL 2025 I 0 Si) M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 1 FTEW1 EF2HFA65674 State Farm ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 Torres. Robert.X. 1768018-SFP-13 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) tSEATI (DOB) (SEX) {SAFT) (AIR) OM (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 0 EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 18 1 02,02 l2025 01 47 ®❑PM in a Work Zone? ®N DIRP co I I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C) o" 2 ❑ 08 99 1 , 0 PM ❑Construction * Z 3 0 DygCITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM ❑Maintenance U2 o ® 11 1 ARREST NAME Mills. Nicholas. R. 11-601-Ax 752599 / ! ❑PM SLMT I$[CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME NAM• 0 Utility t 2 El ARREST NAME Mills. Nicholas. R. 11-501-A-1 751902 02,02 ,2025 02 35 f PM El Unknown work zone type U1 30 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30 1521-Vega.Wendy 102 391-Jacobucci 03 , 10,2025 09 00 ❑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 -< ` ` --I -' r INDICATE NORTH combination):or A 1 1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C L (example:shuttle or charter bus):or C) 3. Is designed to carry15 or fewer passengers and operated a contract carrier 0 - -0 . . . transporting employee in the course of their employment(example:employee transporter-usually a van type vehicle or passenger car):or co �,`:• Not CAM J - } } 1 •4. Is used or designated to transport between 9 and 15 passengers,including the driver. C I. Z' .P for direct compensation(example:large van used for specific purpose):or __ __ '�I� — _ < < ._ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m i'' placarding(example:placards will be displayed on the vehicle). 1 XI. . . . illi•11W 2# i CARRIER NAME —I *III ti J ADDRESS D i1.1t 1, C) CITY/STATE/ZIP I - i. MOTOR CARR.ID 0 Interstate 0 Intrastate I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other --- --1 - USDOT NO. ILCC NO. m 73 Source of above z . GVWR/GCWR m 0 <10,0oo 0 10,000-26,000 0 >26,000 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. 71 73 m Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's Z own tank)? 0 Yes 0 No 0 Unknown D Did HAZMAT Regulations violation contribute to the crash? r ❑ Yes 0 No 0 Unknown g Did Carrier Safety Regulations I/ICS)violation contribute to the crash?❑ Yes IQNo El Unknown Unknown 0 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 LOCAL USE ONLY TRAILER VIN 2 m 0 TRAILER WIDTH(S) 0-96" 97-102" >102' T TRAILER 1 ❑ ❑ 0 z ri TRAILER 2 ❑ 0 0 o u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Gray Gray 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