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HomeMy WebLinkAbout2025-00013251 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 101101100 1111111111111111111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0037419E4 u, 1 U21 1 3 1 UI 2 U2 1 U, 1 1_12 1 U1 1 U2 1 1 10 u1 3 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash 0 AMENDED YR 202512025-00013251 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn BODE RD El In 06:42 ® ❑ RELATED ®Y 0 N 02 28 2025 ❑AM ❑YES ®NO U1 _ _ g PRIVATE mo I day!yr ®PM FLOW CONDITION m FT!MI N E S W E CHICAGO ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR NI SLOW 1 cn ❑ Cook HIT ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 —I ® &RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0 FOR DAMAGEDAREA(S) FRO T TOWED U1 Q Bielat.Craig. H. 0 1 / yr 13-UNDER CARRIAGE ©,I O,._Z FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m M 2 SYTM IN ENGAGE4 ❑Y ®SNE❑UNK VEH. 0 ATCRASHD 0 99-UNKNOWN 916•TOP 3 `Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�a �i COM VEH 0 Ea 1 0 ELGIN I L 60120 0 1 0 FIRST CONTACT 11 7_: __5 *Ilyes.See Sidebar U1 Z VL4004 IL 2020 E TELEPHONE IL 0 3VWPL7AJ2EM618203 Country Il Financial ❑v N U2 m B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m co 99 9 Same P12A3402221 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused 0 Y El 2 0 E{ DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 Mks 0 Nov 0 NCV 0 Dv 1 9 9 9 Nissan Versa 2021 00-NONE ,�_"j Qr-_, DUE TO CRASH ❑ 2 0 13-UNDER CARRIAGE 10( ) 2 FIRE ❑ ® U2 C c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,1r. 6-TOP 3 X ❑Y Ni N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value U1 0 POINT OF S i1 �" COM VEH ❑ ® W N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 12 7 B LC-_5 •Iryes,See Sidebar ZWEST DUNDEE IL 60118 0 1 0 DL5936F IL 2025 I0 C Z IL D 0 3N 1 CN8V6LL884264 Owners Ins. ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X 99 9 Mundo Auto Sales 189097698 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) U2 996 r m ##occs y / U1 1 D 1 0 EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 4 02,28 12025 06 42 ®AM in a Work Zone? ®N DIRP co 1 t PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 3 n T 0 2 ❑ 2 99 + 1 0 PM• ❑Construction X 7 Z 3 0 I!!I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 o ® 11 4 ARREST NAME Bielat.Craig. H. 11-902 455-416 / I El PM SLMT o N - ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility 0 AM F 2 0 ARREST NAME 021 28 12025 06 42 ®PM 0 Unknown work zone type U1 25 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 25 455-Hallac.Gabriel 302 03 1 18,2025 09 00 ❑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 -< c ` -'- ' r INDICATE NORTH combination):or —I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } (example:shuttle or charter bus):or X A 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O t } } transporting employees in the course of their employment(example:employee 73 / transporter-usually a van type vehicle or passenger car):or w L -----------; / t } } •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 O / I. i. i. , 5. Is any vehicle used to transport an hazardous material(HAZMAT)that requires I". placarding(example:placards will be displayed on the vehicle). m N XI D CARRIER NAME Z 1 ADDRESS0 Not To Soak._1 D citimorar. rn CITY/STATE/ZIP 00 MOTOR CARR.ID 0 Interstate 0 Intrastate I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other ;------ --1 - USDOT NO. ILCC NO. m XI Source of above z 0 Yes 0 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' -n TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 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. SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® DISABLING DAMAGE Other/Owners Residence VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE