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HomeMy WebLinkAbout2025-00006765 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111 I01101100 I I1110 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X00371518! u, 1 U21 2 4 1 UI 2 U2 1 U, 1 1_12 1 U, 1 U2 1 5 15 U1 1 U2 1 *P 0119 INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 3 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash 0 AMENDED YR 202512025-00006765 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 "I BUSHWOOD DR El In 05:30 ® ❑ RELATED ®Y 0 N 01 31 2025 ❑AM ❑YES ®NO U1 -< _ _ g PRIVATE mo !day!yr ®PM FLOW CONDITION MFTlMI N E S W TECHNOLOGY DR COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 /83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!Cy 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C) T�TOWED U1 O mo Sloan. Ronald. L. Subaru Forrester 2017 00-NONE ©, Qz a/DUE TO CRASH IN ❑ O NAME(LAST,FIRST,M) yr 13-UNDER CARRIAGE } FIRE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 2 THERDISTRACTED 0 ga U2 0 rI1 M 2 5 SYTM❑Y ®NNE❑UNK VEH. 0 ATCRASHD 0 15-99-UUNKNOWN 9 76•TOP 3 `Distraction Value ALGN X. r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR F. POINT OF $ iI 6 �i 4 COM VEH ® 0 1 0 FIRST CONTACT 9 7 . -_;__5 *II Yea.See Sidebar Ut Z Crystal Lake IL 60014 C 1 0 9657561 IL 2024 Is TELEPHONE IL D 0 J F2SJAWC3H H513206 State Farm ❑Y IlN U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Elgin Fire 99 9 Same 1348116-SFP-13 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ® N 2 XI Eg DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 iiuv 0 i v 0 DV !1 9 9 3 Toyota Camry 2012 00-NONE 0Qj'O DUE TO CRASH 0 ❑ 2 x omo y yr 13-UNDERCARRIAGE 10 FIRE ❑ ® U2 C c M 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X 0 Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN *0istracti n Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 i 6 .!,_4 COM VEH ❑ ® U1 CO FIRST CONTACT 1 7 _, _5 C.If Yes.See Sidebar C ELGIN IL 60120 C 1 0 BR95452 IL 2024 Si)0 Z IL D 0 4T1 BF1 FK5CU612869 First Acceptance Insuranc ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X Elgin Fire 99 9 Same I LFB 000000757 SAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 < Sherman RESPONDER u1 = (UNIT) (SEAT( (DOB( (SEX) {SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 1 3 03 / F 2 4 0 1 0 m / / #OCCS D / / UI 2 D / / 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z u 1 ® 11 1 01 ,31 l2025 05 30 ®pm in a Work Zone? ®N DIRP co 1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 1 C) T o" 2 0 2 06 , , ❑PM ❑Construction 4 Z 3 0 1!>I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME3 ❑AM 0 Maintenance U2 o ® 11 1 ARREST NAME Sloan. Ronald. L. 11-901 4880000227 , ! El PM SLMT o N • ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility 30 t 2 ARREST NAME AM T El ! ❑❑PM El Unknown work zone type U1 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 30 488-Ramos.Arely 901 223-Hughes 03 , 11 ,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 A 1. Has or more than pounds(example:truck or truckrtratler -< 1. Has a weight rating10 000 ' }----r----, I rmrI INDICATE NORTH combination): N 1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C i_ .:.. -:. 1 j I (example:shuttle or charter bus):or 0 r r X I- I- --I. 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O } } } transporting employees in the course of their employment(example:employee X immeremrw. transporter-usually a van type vehicle or passenger car):or w L L.___a__. - - — 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or o L L--_-a-___.I 1-7.„ - 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). T __ D I -I CARRIER NAME Z IDI ADDRESS D (A l m CITY/STATE/ZIP I 0 Not To Scale I - MOTOR CARR.ID 0 Interstate 0 Intrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other -----—: - USDOT NO. ILCC NO. rn XI Source of above z . m Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z own tank)? 0 Yes ® 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?El❑ Yes II No 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 ®No 2 TRAILER VIN 1 m co LOCAL USE ONLY TRAILER VIN 2 m 0 TRAILER WIDTH(S) 0-96" 97-102" >102' T TRAILER 1 0 0 0 Z TRAILER 2 ❑ 0 ❑ o u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Gray Red 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