Loading...
HomeMy WebLinkAbout2025-00007314 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 0000100 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X403715245 u, 1 U21 1 1 1 U1 2 U2 1 U, 1 1_12 1 U, 1 U2 1 1 10 u1 3 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW ' Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and for Tow Due To Crash YR 2025I 2025-00007314 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ® ❑ RELATED ®Y 0 N 02 03 2025 ❑AM ❑YES ®NO U1 -< DIXON AVE Elgin03:58 _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m FT!MI N E S W ST CHARLES ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 ❑ Cook HIT&RUN ❑Y ® N WITH VEHICLESOT, INVLD DO U2 --I El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL ❑EWES ❑uuv ❑!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C) FOR DAMAGEDAREA(S) FROPtf TOWED U1 Q Webster. Rayquan, D. 1 1 / yr 13-UNDER CARRIAGE ©,I '.-2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m M 2 SYTM IN ENGAGEis-OTHER 4 ❑Y ®SNE DUNK VEH. 0 AT CRASHD 0 99-UNKNOWN 9 16•TOP 3 `Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8, i:�—a �i 4 COM VEH 0 0 1 0 F. FIRST CONTACT 11 7_ __;__5 *Ilves.See Sidebar U1 Z SOUTH ELGIN IL 60177 0 1 0 EF48048 IL 2025 REAR TELEPHONE IL D 0 1ZVFT84NX65207154 Diect auto ❑v IlN U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 WEBSTER, HELEN, K. PAIL001223103 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 XI p;rg- DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMV 0 NCv 0 DV $ !1 9 8 9 Jeep(after 1968,�rokee 2001 00-NONE O, t2..-_, DUE TO CRASH ❑ 2 x 0 13-UNDER CARRIAGE 10 I 2 FIRE 0 ® U2 C c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X ❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN `Oistrac on Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-it 6 I1:, 4 COM VEH 0 ® U1 CO FIRST CONTACT 11 7 __5 •If Yes.See Sidebar C Z Carpentersville IL 60110 0 1 0 N376114 IL 2025 REAR 0 Si) D IL D 0 1J4FF48S21 L592937 Progressive ❑Y J N RDEF X1 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X 99 9 Same 13208203 BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER U1 = KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 1 02,03 ,2025 03 58 ®pm in a Work Zone? ®N DIRP co 1 F PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 ✓ 2 ❑ 06 99 02 r 03 ,2025 ❑PM ❑Construction * , R O ❑ ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 3 ❑AM ❑Maintenance U2 o ® 11 1 ARREST NAME Webster. Rayquan. D. 11-801 S1544-000081 02,03 l2025 ❑PM SLMT o N • ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility AM F 2 El ARREST NAME 02 r 03 ,2025 ❑❑PM ❑Unknown work zone type U1 35 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 35 1544-Solis,Yulissa 401 02 ,25,2025 01 30 El NI ®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. A CMV is defined asmotor vehicle used to transportand: r ----,5-••--, ; any passengers or property Z 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -< } i.-- -i-- --; } } } r -, , ; ; , 1, ( INDICATE NORTH combination):or —I p1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } ' i 1 , } (example:shuttle or charter bus):or X 3. Is L L.___A_. 1 <--_- -___� J transporting employened to es Inhecourse 5 or fewer o their eers mplod yment example:employeener X } } } transporter-usually a van type vehicle or passenger car):or co < <.__-a-_-_, , 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 0 L L___-a____.: L L L ...._-..:_____� t i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example:placards will be displayed on the vehicle). XI --I CARRIER NAME Z ADDRESS 0 co CITY/STATE/ZIP MOTOR CARR.ID 0 Interstate ❑ Intrastate 0 ❑ Not in Comm./Govt. ❑ Not in Comm./Other O USDOT NO. ILCC NO. m XI Source of above 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. Xl Xl 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? ❑ Yes II No ElUnknown 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 Black u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO: _ SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE