HomeMy WebLinkAbout2025-00009897 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets III III 11 IIII
IIIIII 01100 010 0
0
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00372853/
u, 9 u21 3 4 1 U, 2 U2 1 U,99 1_12 1 U,99 U2 1 1 15 u, 1 U2 1 *P 0119*
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 El$501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00009897 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 f7
VILLA ST Elgin02:22
® ❑ RELATED ®Y 0 N 02 14 2025 ❑AM ❑YES IX]NO U1
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION Ill
FT!MI N E S W S LIBERTY ST COUNTY PROPERTY El ® N DOORING ❑y #OF MOTOR 0 SLOW 15 '
❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N 51 FREE FLOW # LNS 0
Ig DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEON. 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
FOR DAMAGEDAREA(S) FRO TOWED U1 0
NAME(LAST,FIRST,M) Unknown.0. mo / / yr Ford Fusion 2012 00-NONE „_' Q 1 r T 7T DUE TO CRASH ❑ EN ' E
13-UNDER CARRIAGE *IVi , 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ]$I U2 0
1T1
SYSTEM IN ENGAGED 15-OTHER 9 t6.TOP 3
9 9 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s_iL S !i, COM VEH 0 El 1 00
~ 0 9 FIRST CONTACT 1 7_; __5 *IIYes.See Sidebar Ut
Z DZ40541 IL 2024 REAR
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 11/
3FAHPOJA8CR276748 NIA ❑Y ❑N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
Calvillo. Ebony. M. NIA 1 rn
"o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
99 0
/1 9 5 4 y yr Honda CRV 2018 00-NONE O QI-O DUE TO CRASH ❑ 2
0 13-UNDER CARRIAGE 10( I 2 FIRE 0 ® U2 C
iI
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y ®N DUNK VEH. AT CRASH 99-UNKNOWN `0istractlon Value g g
POINT OF 8 i1�i" 4 COM VEH ❑ ® U1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 12 7 B .5 •If Yes.See Sidebar
ZSartell MN 56377 0 1 0 BD31448 IL 2023 iiEaR 0 N
D
MN D 0 7FARW2H54JE103947 Progressive ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 8 x
Same 927675582 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (D081 (SEX) (SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
1 7 01 /
LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y
N 1 ® 11 9 02(14 l2025 02 22 ®PM AM in a Work Zone? ®N DIRP D
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 25 99
N 3 0 ❑CITATIONS ISSUED 0 PENDING ( 1 ❑PM• ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM 0 Maintenance U2
—a, ARREST NAME / / ❑PM '
o N 1 ® 11 4 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT
30
t 2 ARREST NAME AM
7 1 / ❑❑PM 0 Unknown work zone type U1
El
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
❑Y 30
474-Jacobs.Tyler 401 - ( / El 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
p0
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver n
_ } (example:shuttle or charter bus):or
X
. A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
} } } transporting employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
i. VIIIa7St C
}--- ----; - } } } 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 0
L L____a____.I t i. i i 5. Is any vehicle used to transport anyhazardous material(HAZMAT)thatrequires
j placarding(example:placards will be displayed on the vehicle). XIIII
Unit 1 t
• ■ __ —1
:k CARRIER NAME Z
ADDRESS 0
T.
CITY/STATE/ZIP 0
g
87L1berty781 I - i. i. MOTOR CARR.ID 0 Interstate ❑ Intrastate
I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other
Y Not To Scale j
I USDOT NO. ILCC NO. m
XI
Source of above z
. 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 ❑ 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
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Black 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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE