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HomeMy WebLinkAbout2025-00011578 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 101101100111111110111011 1 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0037.34436 u, 9 U21 3 4 1 u, 2 U2 1 u,99 u2 1 u, 1 u2 1 1 11 u, 1 U2 1 *P 0119 INVESTIGATING AGENCY DAMAGE TO ANY 0$500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00011578 VENT ADDRESS NO. HIGHWAY or STREET NAME El ❑CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 71 RT20 RELATED ®Y 0 N 02 21 2025 09:07 ❑AM ❑YES ®NO U1 —< Elgin PRIVATE mo /day/yr ®PM FLOW CONDITION Ill FT!MI N E S W LAMBERT LN COUNTY PROPERTY El ® N DOORING ❑y #OF MOTOR IR SLOW 1 (n ❑ Cook HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV ❑ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 C) FOR DAMAGEDAREA(S) FROM TOWED U1 0mo Unknown.0. Unknown Unknown 00-NONE ©, >2 �/OUETOCRASH ❑ EN NAME(LAST,FIRST,M) yr 13-UNDER CARRIAGE 10.I 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 3 M 9 3 SYSTEM IN 9 ENGAGED 9 (�-OTHER 9 16-TOP 3 ' _ ❑Y ❑N CO LINK VEH. AT CRASH 9 UNKNOWN 5 4 `Distraction Value ALGN r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 �i COM VEH 0 j$J 1 0 I— 0 1 0 FIRST CONTACT 12 7_; __5 *If Yes.See Sidebar U1 ZUNKNOWN Unknown TELEPHONE UNK. 9 UNKNOWN UNKNOWN ❑y ®N U2 m SI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same UNKNOWN 1 rn `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER r RESPONDER® 0 m N DRIVER ❑ PARKED ❑DRIVERLESS ❑ PEo ❑PEDAL ❑EWES ❑M/V 0 i v ❑Dv 1 9 6 0 Audi Q3 2024 00-NONE 'o,I 12 (,�2 FIRE DUE O CRASH 0 ® U2 2 73 C o mo Yr 13-UNDER CARRIAGE F 2 4 SYSTEM IN 0 ENGAGED 9 ®-OTHER 9.1,6•TOP 3 9 0 X ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistrac on Value POINT OF 8 i 4 F.OM VEH ❑ ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6 FIRST CONTACT 6 O7 ,�_QIOS •It Yes See Sidebar C CAROL STREAM IL 60188 0 1 0 EW20137 IL 2024 REAR 0 Si) IL D 0 WA1EECF33R1044277 Allstate ❑y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X 99 9 Same 811072747 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 0 Y U2 Z N 1 ® 11 1 02,21 /2025 09 07 ®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 � 57 2 28 03 N 3 ❑ 0 CITATIONS ISSUED 0 PENDING + ) ❑PM- ❑Construction SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 3 —a, ARREST NAME / / _ ❑PM 1 ® 1 1 1 Utilit SLMT o N SECTION CITATION NO. ROAD CLEARANCE TIME ❑ y ❑CITATIONS ISSUED PENDING t 2 El ARREST NAME 02 r 21 12025 10 00 ®PM El Unknown work zone type U1 0 AM 45 x T n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ 485-Quintana.Josue 401 ❑AM Workers present? ❑N 45 r r ❑PM ® 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 -< } }---_r____. — 1 - } combination):or INDICATE NORTH Not To Scale C i _ 1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver (example:shuttle or charter bus):or n L r 3. Is designed to carry15 or fewer passengers and operated a contract carrier O - }-_---;----; - . } } } transportingemployees In the course of their employment(example:employee X «t I transporte -usually a van type vehicle or passenger car): r co — — — < I. 4. Is used or designated to transport between 9 and 15 passengers,including (I) }--- + �"' } } } g po passen rs,includi the driver, for direct com— — — — pensation(example:large van used for specific purpose):or L 42. t I I I 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 7 C placarding(example:placards will be displayed on the vehicle). XI CARRIER NAME —I ADDRESS ro CITY/STATE/ZIP g Ii.r i i. i. 4. 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. rTt XI Source of above 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 v TRAILER WIDTH(S) 0-96" 97-102" >102' m TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Blue 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/TO: DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE