HomeMy WebLinkAbout2025-00007945 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets Mil III H iinii
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El5501-51.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 2025I 2025-00007945 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 m409 HUBBARD AVE Elgin07:43
® ❑ RELATED ❑Y ®N 02 06 2025 ®AM ❑YES ®NO U1 -<
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 u)
❑ FT!MI N E S W Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Qg3 DRIVER t] PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 1 C)
0 8 !
yr 13-UNDER CARRIAGE 10.I 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 1 r<r1
F 2 SY 15-OTHER
4 ❑Y ®SNE❑UNK VEH. 0 AT CRASH M IN D 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, i�S 4 COM VEH 0 j$J 4 0
~ ELGIN I L 60123 0 1 0 FIRST CONTACT 12 7 ; _5 *Yves.See Sidebar U1
Z FD41816 IL 2026 REAR
TELEPHONE
IL D 0 1 C4HJXDGOMW715329 Progressive ❑Y ®N U2 31 , m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
co
99 9 Same 979297229 4 m
I—
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ❑ N 2 0
❑ DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 M/v 0 NOV 0 Dv CIRCLE NUMBER(S) U1
!1 9 y 7 Hyundai Venue 2023 00-NONE 'o,� t2 c,�2 FIRE DUE o CRASH ® U2 2 xl
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o 13-UNDER CARRIAGE
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F 1 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X
❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value g g
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 1 S .t. 4 COM VEH D ® Ut CO
F,,, FIRST CONTACT 6 O7 ,�=Q)OS C.
IT Yes,See Sidebar C
ELGIN IL 60123 0 1 0 EK6TOL MO 2025 FIRST
Si)0
M
MO D 0 KM H RB8A36PU275041 Allstate ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
99 9 Same 811905588 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND 0 N u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
0 O
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2Z
N 1 ® 18 1 02/06 l2025 07 43 ®❑AM
in a Work Zone? Igi N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
o"
2 ❑ 28 11 , / ❑PM• ❑Construction *
R 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM 0 Maintenance U2
-, ® 11 1 ARREST NAME Olivera.Jennifer 11-1427-H- 1543000075 / ! El PM SLMT
o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility
AM U1 25
T 2 ❑ ARREST NAME 02l 06 12025 08 00 [M PM ❑Unknown work zone type
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 25
1543-Sturgeon. Kyle 600 275-Engelke 02 ,25,2025 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•---, , I ; 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 truckrtrailer -<
i- }-- ''-- --1 I r^ - INDICATE NORTH combination):or -I
I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} Ei. \ ,._..-,�, N _ (example:shuttle or charter bus):or 0
,� ��, � 3. Is designed to carry15 or fewer passengers and operated a contract carrier I 0
---_------1 1 p�
- } } } transporting employee In the course of their employment� (example:employee X
v
a
< <.___a____� I l� I rP edord�llnatedtotransehrtbetween9andr15r) ssen rs,including[hedriver,
OGkly9Ara J } } I-
.:. for direct compensation(example:�large van used for specific purpose):or
i L i i L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). XI
—N. CARRIER NAME Z
I ADDRESS
T.
CITY/STATE/ZIP 0
I Not To Scalei. MOTOR CARR.ID 0 Interstate 0 Intrastate
1 I , , ❑ Not in Comm./Govt. Not in Comm./Other
❑ 00
i""Y""1 I USDOT NO. ILCC NO. C
m
XI
Source of above z
. If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. XI
XI
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
0
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 Silver
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 2 TOWED BY/TO:
_ 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