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HomeMy WebLinkAbout2025-00010612 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I01101100 101111110111100 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003135619 u, 1 U2 2 4 1 U1 1 U2 U, 1 U2 U, 1 U2 5 6 U1 3 U2 *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 51,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash El AMENDED YR 2025I 2025-00010612 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 �I TECHNOLOGY DR Elgin 10:31 ® ❑ RELATED ' V 0 N 02 17 2025 ❑AM ❑YES ®NO U1 —< _ _ g PRIVATE mo !day!yr ®PM FLOW CONDITION MFT!MI N E S W VANTAGE DR COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR El SLOW Cl)❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0 FOR DAMAGEDAREA(S) FROM TOWED U1 0 Ayush.Sainnyambuu 0 9 / yr 13-UNDER CARRIAGE ©,I 0• ,:0 FIRE ❑ ® C STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 rn M 2 8 SYTM❑Y ®SNE❑UNK VEH. 0 ATCRASHD 99-UUNKNOWN THER9 t6•TDP 3 `Distraction Value 9 ALGN = T CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6.;ii_6 1,.4 COM VEH 0 E! 1 0 ~ ELGIN N I L 60124 0 1 0 FIRST CONTACT 12 7 ; _5 *IIYes.See Sidebar U1 Z 3547089B IL 2026 REAR TELEPHONE IL D 0 3TMCZ5ANOJM122981 Progressive Insurance ❑Y Il N U2 ni in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same 919756666 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y El 2 ou 0 DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 yr 12 _ C1 o 13-UNDER CARRIAGE 10 I c. 2 FIRE ❑ ❑ U2 C c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED LT_ SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 0 ❑ SPDR 0 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value U1 0 - POINT OF s-.;, 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRSTO CONTACT Y 6 I,_ CIOMs gee SidebarH 0 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 < RESP❑YD❑N NDER U1 = (UNIT) (SEAT) (DOBi (SEX) {SAFT) (AIR) (WI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 0 1 3 10 / F 1 5 0 1 0 I71 / / #OCCS > / / UI 2 D / / 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 43 3 02/18 /2025 10 31 ®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 v t 2 ❑ 28 15 02/17 /2025 10 31 ®PM ❑Construction Z 0 El CITATIONS ISSUED PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM El Maintenance U2 _a 3 ARREST NAME Ayush.Sainnyambuu 11-601-Ax 1527000277 ! ! ❑PM SLMT o u1 ❑ CITATIONS ISSUED PENDING Utility o N SECTION CITATION NO. ROAD CLEARANCE TIME ❑ t 2 El ARREST NAME 02/18 /2025 10 31 ®PM ❑Unknown work zone type Am U1 35 n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑Y ❑AM Workers present? 2 3 ❑ 1527-Juarez.Jorge 901 223-Hughes 03 ,25/2025 01 30 0 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••--, , I A CMV is defined as any motor vehicle used to transport passengers or property and: z -< i- `-----l-----' I i - INDICATE NORTH combination):or rating more than 10,000 pounds(example:truck or truckrtrailer 1. Has a weight BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C I - (example:shuttle or charter bus):or X I < <-----1----' I A transporting mployeeslin 5 he courses passengersr thir emplod yment example:employeener X • T } r } j transporter-usually a van type vehicle or passenger car)or i. i. __}----I. / afAt - } } 1 •4. Is used or designated to transport between 9 and 15passengers,including the driver. C `��AO for direct compensation(example:large van used fors specific purose):or L L____a____� �p . .. L t 5. Is anyvehicle used to transport anyhazardous material(HAZMAT)that requires 'D f T placardig(example:placards will be isplayed on the vehicle). XI . 1 CARRIER NAME Z ADDRESS 'n I I T. 0 CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate 0 Intrastate I . ❑ Not in Comm./Govt. 0 Not in Comm./Other --- --1 - USDOT NO. ILCC NO. rn XI Source of above Z . If Yes,Name on placard 0 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 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' m TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U_COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Gray u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO: Arties . 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