HomeMy WebLinkAbout2025-00007941 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100 VI
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ❑OVER 51,500 El NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
0 AMENDED YR 2025I 2025-00007941 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I
1200 MAROON DR El In07:34
® ❑ RELATED ❑Y ®N 02 06 2025 ®AM El YES ®NO U1 -<
g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
_
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW Cl)
❑ FT/MI NESW Cook HIT ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 --1
&RUN
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUCE 0 KIN 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
0 8 !
yr
Kmilek.Agnieszka.A. Nissan Pathfinder 2018 00-NONE „ •
Q 0 DUE TO CRASH ® ❑
13-UNDER CARRIAGE lo i 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED ❑ 0 U2 m
F 2 4 SY❑Y ❑SNE®UNK VEH. 9 AT CRA IN SH 9 15-OTHER
99-UNKNOWN 9 t6•TOP 3 `DlstractionValue 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ ;i�B 4 COM VEH ❑ j$J 1 0
0
" �- STREAMWOOD IL 60107 0 1 0 FIRST CONTACT 12 T ; _5 *II Yes.See Sidebar u1
ZBX22499 IL 2025 E
TELEPHONE
IL D 5N1 DR2MM3JC661100 Progressive Insurance ❑Y ®N U2 r
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
Same 972407497 4 m
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER XI
Refused ❑Y ❑ N 2 0
0 DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 row
yr 12 _ X1
o 13-UNDER CARRIAGE 1U I c. 2 FIRE 0 ❑ U2 C
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 916-TOP 3 El El SPDR 0
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN POINT OF 8 *Oistrac) n Value 0 -
- 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT Y •
+:-5 C•IO e1sVSee SidebarEH ❑ 0
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M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O
❑Y ❑N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
BAC
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
RESP❑YD❑N NDER U1 =
(UNIT) (SEATI (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 43 2 Elgin High School Chainlink Fence-12ft 02/06 /2025 07 34 ®❑PM AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 10
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
v t 2 ❑ 1200 MAROON DR ELGIN IL 60120 11 15 ! ! ❑PM ❑Construction >F
Z3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2
-a, ARREST NAME / / ❑PM '
o N 1 ❑ 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT
15
t 2ARREST NAME AM
7 ! r ❑❑PM El Unknown work zone type U1
Eln OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y
2 3 ❑ ❑AM Workers present? ❑
483 Lynch. Miriam 300 275-Engelke ! ! ❑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 -<
` ` -' -' r INDICATE NORTH combination):or .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- } (example:shuttle or charter bus):or
X
I------:-- _ 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
- . I- . transporting employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
L I , - •} } 1 4. Is used or designated to transport between 9 and 15 passengers,including the driver. N
for direct compensation(example:large van used for specific purpose):or O
L _ t 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). ;p
', Q CARRIER NAME Z
_kw mom.1 i. i. , __ ' ADDRESS 0 w
0
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate ❑ Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
-"--------1 - USDOT NO. ILCC NO. rn
XI
Source of above z
. -I
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? A
❑ Yes II El 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 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_COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Other/Owners Residence . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U_TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO:
DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE