HomeMy WebLinkAbout2025-00007466 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003715262
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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 14
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
0 AMENDED YR 202512025-00007466 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I
® ❑ RELATED ®Y 0 N 02 04 2025 ®AM ❑YES ®NO U1 -<
SPARTAN DR Elgin10:55
_ _ g PRIVATE mo !day/yr ❑PM FLOW CONDITION III
FT!MI N E S W DU FFY DR COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ Kane HIT ❑Y ® N WITH VEHICLES INVLD El STOPPED U2 —I
® &RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Qg3 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)
1 0 !
yr 13-UNDERCARRIAGE 101 •�. 2 FIRE ❑ al
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 0 171
F 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 16.TOP
�3 * _
El N ❑UNK VEH. AT CRASH 99-UNKNOWN Distraction Vatuc ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6_iL 6 if._4 COM VEH 0 181 1 0
~ Hampshire IL 60140 0 1 0 FIRST CONTACT 3 7_; __5 *Ir Yes.see sidebar U1
Z P DR16800 IL 2025 ' E
TELEPHONE
IL D 1 J8G R48K57C615176 State Farm ❑Y ®N U2 M
.5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire Loss, Michael,A. 1655320SFP13 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 ou
m Ei{ DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 iiuv 0 Ncv 0 Dv
!2 O 0 6 Audi A7 2016 00-NONE ,i_"j Q�-_, DUE TO CRASH ❑ 2
o 13-UNDER CARRIAGE 10( I. 2 FIRE 0 El U2 C
M 2 4 ❑Y ❑SYSTEM IN ENGAGED 15-OTHER 9,16-TOP 3 0 X
❑N UNK VEH. AT CRASH 99-UNKNOWN `Oistraellon Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-iI�1:,-4 COM VEH ❑ ® U1 CO
FIRST CONTACT 12 7 _, .5 •• •IfYes,See Sidebar
H ELGIN IL 60124 0 1 DP28849 IL 2025
M
IL D WAUW2AFC6GNO15916 State Farm ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
Elgin Fire Same 3392009SFP13 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPOND❑N 3 u1 =
(UNIT) (SEAT) (DOBi (SEX) {SAFT) (AIR) (INJI (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 4 02,04 l2025 10 55 ®❑pM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1
v 2 0 2 99 02/04 ,2025 11 06 ❑PM ElConstruction *
R O 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
3 ®AM ❑Maintenance U2
-a, uSECTION CITATION NO. ROAD CLEARANCE TIME
ARREST NAME Loss. Kayla.A. 11-901 298001186 02,04/2025 1 1 1 0 ❑PM SLMT
1 ® ElUtilit 11 4 0 CITATIONS ISSUED PENDING
o y
AM 30
r 2 El ARREST NAME 02!04 ,2025 11 55 MPM 0 Unknown work zone type U,
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 0
AM Workers present? ❑Y 30
298-Lopez, Mirko 702 275-Engelke 03 , 10,2025 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
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -
c ` --I -' r INDICATE NORTH combination):or -I
Not To Scale I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i_ * y - i. e. r (example:shuttle or charter bus):or 0
3. Is designed to carry 15 or fewer passengers and operated a contract carrier 0
-- -- _ J _ - . I- . transporting employees in the course of their employment(example:employee X
---; spntUn?DL
•fit transporter-usually a van type vehicle or passenger car):or co
C
unn z _ t >• •4. Is used or designated to transport between 9 and 15 passengers,including the driver, (I)
for direct compensation(example:large van used for specific purpose):or o
L L____a____. it`— r l. i i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). ;p
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`� l CARRIER NAME Z
ADDRESS 'n
n
CITY/STATE/ZIP g
MOTOR CARR.ID ❑ Interstate ❑ Intrastate
r ; ❑ Not in Comm./GaA. Not in Comm./Other0
--- --1 - USDOT NO. ILCC NO. m
XI
Source of above z
. 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' -n
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Red 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 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