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HomeMy WebLinkAbout2025-00012454 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 101101100 lflfl III ilfiifi1II HtI II DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003737,O4 u, 1 U21 1 1 1 U1 7 U2 1 U, 1 1_12 1 U, 1 U2 1 1 11 U1 1 U2 1 *P 0 1 1 9* 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 1215501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ❑OVER 51,500 El NOT ON SCENE(DESK REPORT) El AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00012454 VENT ADDRESS NO. HIGHWAY or STREET NAME El ❑CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 71 RT20 RELATED ❑Y ®N 02 25 2025 03:23 ❑AM ❑YES El NO U1 -< Elgin PRIVATE mo /day/yr ®PM FLOW CONDITION Ill • 010 ®!MI N E s © WEST RIDGE Dr COUNTY PROPERTY ❑Y ® N DOORING El #OF MOTOR ElSLOW 3 Cl) 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 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0 4 / Lincoln MKX 2010 00-NONE 11_' Q 1 7.1 DUE TO CRASH ❑ EN ' E 13-UNDER CARRIAGE 10 i , 2 FIRE 0 IE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m M 2 SY4 ❑Y ®SNE❑UNK VEH. 0 AT CRAS IN H 0 15-OTHER 99-UNKNOWN 9 16•TOP 3 `Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $,_. ; 0 1 a �i-- 4 COM VEH 0 j$J 1 0 F. FIRST CONTACT 1 7 ___5 *IIYes.See Sidebar Ut Z GILBERTS IL 60136 0 1 EB11548 IL 2025 TELEPHONE IL D 0 2LMDJ6JC5ABJ16062 Progressive ❑Y IglN U2 1- 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Carpenter. Lauren Myk. D. 976942052 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 ou p; DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED 0 PEDAL 0 EWES ❑Nuy 0 Ncv ❑DV 1 9 yf 8 Chrysler Town&Country 2015 00-NONE 11_"I t2..-_1 DUE TO CRASH ❑ 2 x 0 13-UNDER CARRIAGE 10'i 2 FIRE 0 El U2 C c ® F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X ❑Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN *Oistraglon Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 5 1 S l:; COM VEH ❑ ® Ut CO FIRST CONTACT 7 O7 :_ _5 •IfYes,See Sidebar ELGIN IL 60120 0 1 ZZ82390 IL 2025 FIRST M IL D 0 2C4RC1 CGOFR727926 State Farm ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Same 1416759-SFP-13 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 < Refused RESPONDER U1 = (UNIT) (SEAT) (D081 (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(A.DDRESS)/(TELEPHONE) (EMS) (HOSPITAL) 1 3 09 / F 2 4 0 1 m / / #OCCS D / / UI 2 m / / 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 21 ,51 ,025 03 23 ®pm in a Work Zone? ®N DIRP co 1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 0 2 03 20 { ) ❑PM ❑Construction * Z 3 0 Igi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 ❑AM 0 Maintenance U2 a ® 11 1 ARREST NAME Brisco. Lucas. R. 11-710-A S1507000358 / r El PM SLMT o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility 0 AM t 2 El ARREST NAME 21 r 51 1025 04 00 0 PM El Unknown work zone type U1 45 2 2 3 ❑ OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 45 1507-Ruiz.Alondra 801 41 , 12 ,25 01 30 ®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. A CMV is defined asmotor vehicle used to transportand: r ----,5-••--, ; any passengers or property Z 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< } i.-- -i-- --; } } } r -, , ; ; , 1, ( INDICATE NORTH combination):or —I p1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } ' i 1 , } (example:shuttle or charter bus):or X 3. Is L L.___A_. 1 <-- . -___� J transporting employened to es inhecourse 5 or fewer o their eers mplod yment example:employeener X } } } transporter-usually a van type vehicle or passenger car):or CO < <.__-a-_-_, , 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 L L ...._-..:__ ; 1 t i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example:placards will be displayed on the vehicle). ,Zmt --I CARRIER NAME Z ADDRESS 0 co CITY/STATE/ZIP MOTOR CARR.ID 0 Interstate ❑ Intrastate 0 ❑ Not in Comm./Govt. ❑ Not in Comm./Other O USDOT NO. ILCC NO. m XI Source of above z . —I Were HAZMAT placards on vehicle? 0 Yes 0 No = 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 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 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Silver 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: 1 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE