HomeMy WebLinkAbout2025-00009472 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X003728543
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INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT El A 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) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 202512025-00009472 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 r7
N LIBERTY ST Elgin 02:19
® ❑ RELATED ❑Y ®N 02 12 2025 ❑AM ❑YES ®NO U1 -<
_ _ g PRIVATE mo !day!yr ®PM FLOW CONDITION MFTlMI N E S W DIVISION ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW Cl)
❑ 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
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 Peoa- 0 EouES 0 NOV 0 Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
0 3 /
Nissan Rogue 2017 00-NONE 11 •
Oi-1 DUE TOCRASH ® ❑
13-UNDER CARRIAGE 10 , 2 FIRE 0 NIC
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 rn
M 2 SYTM 4 ❑Y ®SNE DUNK VEH. 0 AT CRASH 99-UNKNOWN THER9 t6•TOP 3 *Distraction Value 9 ALGN
-
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _iL 6 I,.4 COM VEH 0 LK 2 0
~ ELGIN I L 60120 0 1 0 FIRST CONTACT 12 7_; _5 *II Yes.See Sidebar U1
Z EY15166 IL 2025 REAR
TELEPHONE
IL D 0 JN8AT2MT6HW141616 N/A ®Y ❑N U2 m
5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
co
1 99 9 Same N/A 3 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y ® N 9 2 eu
0 DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0
yr 12 _ 71
o 13-UNDER CARRIAGE 10 I c. 2 FIRE ❑ ❑ U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 ❑ ❑ SPDR 0
❑Y ❑N 0 UNK VEH. AT CRASH 99-UNKNOWN *Distraction
value U1 3 -
POINT OF s-.;, 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRSTO CONTACT Y 6 I._
CIOMs gee SidebarH
❑ C
CO
F` REAR` co
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O
❑Y ❑N RDEF
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 <
RESPNDER❑YD❑N U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 0
1 3 02 / F 2 4 0 1 0
I71
/ / #OCCS >
/ / u1 2 D
/ / 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 43 1 Com Ed pole 02,12 /2025 02 27 ®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 t 2 0 350 S ECO N D ST ELGIN IL 60123 11 28 1 / 0 AM El Construction *
Z3 ❑ j i CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2
-a, ARREST NAME CAC CAAL.CARLOS. E. 6-101 374001293 / / El PM
o U 1 0 �!CITATIONS ISSUED ❑PENDING UtilitySLMT
o N SECTION CITATION NO. ROAD CLEARANCE TIME El AM• ❑
t 2 El ARREST NAME CAC CAAL.CARLOS. E. 3-707 374001294 021 12 /2025 02 53 ®PM El Unknown work zone type U1 30
2 3 0
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y
374-Rizzu-o. Michael 301 272-Bajak 03 /04,2025 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.
.- .. , ® A CMV is defined as any motor vehicle used to transport passengers or property and: Z
r r N.?LIBERTV?OT Z
1. Has a weight rating more than 10,000 pounds(example:truck or truck/trailer
} -' I r INDICATE NORTH combination):or 30
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} I - } r (example:shuttle or charter bus):or
Not To Scale 3. Is desgned to car 15 or fewer ssen ers and o rated a contract carrier O
L I } } } transporting employees In the courses of their employment(example:employee 73
DMBION?eT ' ' ' transporter-usually a van type vehicle or passenger car):or 0
L L.__-a__ 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including C} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or O
L i l. i i ._ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D
placarding(example:placards will be displayed on the vehicle). 73
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�' CARRIER NAME
LLLL. �'"4�
ADDRESS T.
NI w
p44 CITY/STATE/ZIP 0
I - i. i. i. MOTOR CARR.ID 0 Interstate 0 Intrastate
. I . . ❑ Not in Comm./Govt. 0 Not in Comm./Other O
i- -- . ._; I - USDOT NO. ILCC NO. m
XI
Source of above Z
. 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
v
TRAILER WIDTH(S) 0-96" 97-102" >102' T
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.
_Adieu/Impound Lot Garage . 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