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HomeMy WebLinkAbout2025-00009492 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II III HH II11II OHI 00110001111011111111I1VV DRAC TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY XL03728554. u, 1 U21 3 4 3 U1 4 U2 1 u, 1 1_12 1 u, 2 u2 1 1 10 u, 4 U211 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ❑ 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 f or Tow Due To Crash 0 AMENDED YR 202512025-00009492 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n BOWES RD El In04:01 ® ❑ RELATED ®Y 0 N 02 12 2025 12,— ❑YES ®NO U1 —< g PRIVATE mo !day/yr ®PM FLOW CONDITION m FT l MI N E S W SHASTA DAISY DR COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR IR SLOW 15 ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0 0 5 ! Hyundai Sonata 2018 00-NONE ©,: Q _, DUE TOCRASH ® ❑ O 13-UNDER CARRIAGE } FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 2 DISTRACTED 0 0U2 0 m F 2 SYTM IN ENGAGE15-OTHER 4 ❑Y ®SNE❑UNK VEH. 0 AT CRASHD 0 99-UNKNOWN 016•TOP 3 *Distraction Value ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ iI 6 �i COM VEH 0 0 1 0 w ~ ELGIN IL 60124 0 1 0 FIRST CONTACT 11 7 ; __5 *Il Yes.See Sidebar U1 Z EX87730 IL 2024 Isui TELEPHONE IL D 0 5NPE24AF5JH708971 1779602-5FP-13 0Y ® 4 U2 I-- 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR co 99 9 Johnson.Tywana. M. State Farm 3 m `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 XI x DRIVER 0 PARKED 0 DRIVERLESS ❑ FED 0 PEDAL 0 EWES 0 Ntry 0 Nev 0 Dv !1 9$9 Ford Flex 2012 00-NONE 'o,1 t2 c,�2 FIRE DUE ID CRASH 0 ® U2 2 C o 13-UNDER CARRIAGE Ti F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istrac)Dn Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 0'i 6 iY 4 COM VEH ❑ ® u1 CO C FIRST CONTACT 8 Q __, _5 •(ryes,See Sidebar ELGIN IL 60123 0 1 0 BL20702 IL 2024 REAR Si)0 Z IL D 0 2FMGK5DCXCBD0386 State Farm ❑y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Same 3359342-SFP-13 BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER u1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(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 1 02,12 l2025 04 01 ®PM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 � 2 ❑ 11 28 N 3 ❑ 0 CITATIONS ISSUED 0 PENDING + ! - ❑PM• ❑Construction >F SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 —a, ARREST NAME / / ❑PM ' 1 El 11 1 ❑CITATIONS ISSUED PENDING SLMT o N SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utilit y r 2 El ARREST NAME 02)12 12025 04 40 0 PM ❑Unknown work zone type U1 30 x 0 AM T n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ ❑AM Workers present? ❑Y 30 488-Ramos.Arely 801 - 1 / ❑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 -' I. INDICATE NORTH combination):or BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C CO _ . rrr (example:shuttle or charter bus):or �.. 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 liknoN transporter-usually a van type vehicle or passenger car):or CO L L.__-a__. - - 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or 0 L L.._-a____. - L i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example:placards will be displayed on the vehicle). XI �. ♦'' .' > -4_,!, . 1 CARRIER NAME Z m I I ADDRESS D I I m rn Not To Scale j CITY/STATE/ZIP 0 ( I - i. i. i. MOTOR CARR.ID 0 Interstate El Intrastate 1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other -"-------1 - USDOT NO. ILCC NO. rn 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 T. 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 to LOCAL USE ONLY TRAILER VIN 2 m 0 TRAILER WIDTH(S) 0-96" 97-102" >102' T TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Silver Gray 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 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO: DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE