HomeMy WebLinkAbout2025-00008859 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100
VI 101001
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003721:30
u, 9 U2 1 1 1 U1 99 U2 U199 1_12 U,99 U2 1 4 9 u, 1 U221 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ❑ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500
®NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00008859 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 '1
1155 MORTON AVE El08:30
® ❑ RELATED ❑Y ®N 02 10 2025 Ilk- ❑YES El NO U1 —<
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR IR SLOW 15 u)
❑ FT/MI N E S W 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
g DRIVER I] PARKED 0 DRIVERLESS 0 PED p PEDAL 0 EWES 0 NW 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
! ! FOR DAMAGEDAREA(S) FRONT TOWED U1 Q
Unknown.O. Unknown Unknown 00-NONE „ 12 , OUETOCRASH ❑ EN
NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE IE
101 ! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTEDU2 2 <
9 3 SYSTEM IN 9 ENGAGED 9 15-OTHER 9 16-TOP 3 0 ' _
❑Y ❑N CO LINK VEH. AT CRASH 99-UNKNOWN 6 l 4 `Distraction Value 9 ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF iL 6 1i COM VEH ❑ )g! 1 0
H 0 9 0 FIRST CONTACT 99 7_: __5 *II Yes.See Sidebar U1
ZUNKNOWN Unknown REAR
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1
UNKNOWN unknown ❑Y ON U2 I-
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same unknown 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF`Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
.5D Y N 0
5, 0 DRIVER I} PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 r My 0 NOV 0 DV
yr Ford C-Max 2013 00-NONE 1.,-1
12..- , DUETO CRASH ❑ ® 1 7:1
o 13-UNDER CARRIAGE 10;1 c. 2 FIRE ID El U2 C
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ElSPDR n
SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP
3 9 0 X
a ❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN *0istrac on Value
6 ) "4 ut
H POINT OF
CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR O �}._ COM VEH ❑ ® CO
FIRST CONTACT 7 7 .__, _5 •If Yes.See Sidebar
EL63512 IL 2013 REAR0 Si)
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
1 FADP5BU3DL500111 American Alliance ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same I LAA1 01 081 2-00 BAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
RESPOND❑YigN U1 =
Y
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 18 3 02,10 /2025 10 33 ®❑PM in a Work Zone? ®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 U,
2 0 18 18
N 3 0 CITATIONS ISSUED 0 PENDING + 0 PM ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5
z
—a, ARREST NAME / / ❑PM '
ou ® 11 3 ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT
r 2 ❑ 25
AM
T 1 r 0❑PM 0 Unknown work zone type U1
ARREST NAME
nlx— OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 25
486-Munoz.Jasmine 102 - r i ❑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 -<
i- }---_r----; - INDICATE NORTH combination):or
p3
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
IS j I I-
.`I „ } (example:shuttle or charter bus):or
L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
ill } } } transporting employees in the course of their employment(example:employee X
196X2 � I 1 transporter-usually a van type vehicle or passenger car):or CO
81U117< I. 4. Is used or designated to transport between 9 and 15 passengers,including cC/t
}-----;----; - } } } g po passen rs,includi the driver,
for direct compensation(example:large van used for specific purpose):or O
L i — — — — — — t i i. L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D
placarding(example:placards will be displayed on the vehicle). ,Zmt
—1
1 r ' . i. L. 1..- CARRIER NAME ADDRESS Z
'Z
T.
1 41ill
Not To Scale f
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
--- --1 - USDOT NO. ILCC NO. m
XI
Source of above z
. • m
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 ❑ 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
Blue
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 9 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE