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HomeMy WebLinkAbout2025-00011333 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100 lfl IV 110111110 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003734.511 u, 9 U2 1 1 1 U1 4 U2 1 U,99 1_12 U,99 U2 1 4 9 U1 1 U221 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash 0 AMENDED YR 202512025-00011333 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n STEWART AVE Elgin ® ❑ RELATED ❑Y ®N 02 20 2025 DAM ❑YES El NO U1 -< PRIVATE mo /day/yr 08:04 ®PM FLOW CONDITION III 03040,MI NOS W Trout Ave COUNTY PROPERTY El'COUNTY ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n Cook HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 -I 0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 gi DRIVER I] PARKED El DRIVERLESS 0 PED p PEDAL 0 EWES 0 NW 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0 FOR DAMAGEDAREA(S) FROf'rr�TOWED U1 Q Unknown.0. Honda Civic 2007 00-NONE ©, O DUE TO CRASH ® ❑ NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE } O., ,,O FIRE 0 ® < STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ]$I U2 m 9 8 SYSTEM IN 9 ENGAGED 9 15-OTHER 916.70P�3 * _ ❑Y ❑N ®UNK VEH. AT CRASH 99-UNKNOWN Detraction Value 9 ALGN r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6_i� 6 I COM VEH 0 j$J 1 0 I- B 9 0 FIRST CONTACT 2 7_: -_5 *rrYes.See&debar Ut Z EC11422 IL 2025 Ismi TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1) 2HGFA16847H506562 Unknown ❑Y ❑N U2 I— in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Serna. Hector Unknown 1 rn `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER r D Y°®N ( C)) 5, 0 DRIVER I} PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 l uv 0 NOV 0 DV CIRCLE NUMBER(S) U1 yr Volvo S80 2008 00-NONE N_... 12.._-1 DUE TO CRASH ❑ ® 1 7:/13-UNDER CARRIAGE I l 2 FIRE 0 El U2 C 0 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 ® SPDR 0 a SYSTEM IN 9 ENGAGED 9 15-OTHER 00 TOP 3 X ❑Y ❑N CEIUNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF O.I I4 COM VEH ❑ ® Ut CO F,,, FIRST CONTACT 10 O7 6 ll_5 •It Yes.See Sidebar C FB43044 IL 2025 REAR0 fp M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 YV1AH992481054021 None ❑Y ®N RDEF X EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 CANTU.JOSE None BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP 996 < RESPONDER Y°®N U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1{ADDRESS)1(TELEPHONE) (EMS) (HOSPITAL) 0 E/ MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 18 1 02,20 /2025 08 04 ®AM in a Work Zone? ®N DIRP co I I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C) 2 ❑ 28 20 N 3 0 CITATIONS ISSUED 0 PENDING 1 1 0 PM, ❑Construction >F SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 7 -a, ARREST NAME / / 0 PM ' o N ® 11 3 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT 30 r 2 0 ARREST NAME AM T 1 r ❑❑PM 0 Unknown work zone type U1 n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 475 Williarts. Brianna 201 - , i ❑AM Workers present? ❑Y ❑PM ®N U2 35 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 truckrtrailer -< ` ` -' -' r INDICATE NORTH combination):or .Z-1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C - (example:shuttle or charter bus):or r r r X i i i i I 3. Is designed to carry15 or fewer passengers and operated a contract carrier O -- I N - } } } transporting employee in the courses of their employment(example:employee73 transporter-usually a van type vehicle or passenger car):or w L L.___a____� Lwins. 4. Is used ordesi natedtotrans rtbetween9and15 ge ng N } } } g transport specific p passengers,including the driver, w...... for direct compensation(example:large van used fors cific purpose):or O __ — — — vm . - i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m placarding(example:placards will be displayed on the vehicle). ;p —1 _ CARRIER NAME Z ADDRESS 0 1 I r i. i. i. i. 4. w D Not To Scale o CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate 0 Intrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other ----- ----1 - USDOT NO. ILCC NO. rn XI Source of above Z . ❑ Yes II No ❑ Unknown A 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' T TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 ❑ o u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Gray Black 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: 9 TOWED BYlT6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE