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HomeMy WebLinkAbout2025-00013291 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II III H IIIIII DIII 0110001 1111111 111111111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003743581 u, 9 U29 1 1 1 U110 U2 1 U,99 U299 U,99 U2 99 5 12 u, 2 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ❑ON SCENE 14 VEHICLE/PROPERTY El OVER$1,500 ®NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00013291 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH gg -n N STATE ST Elgin ® ❑ RELATED ❑Y ®N 02 28 2025 ❑AM ❑YES El NO U1 10:25 _ PRIVATE mo /day/yr ®PM FLOW CONDITION Ill FT N E S W BIG TIMBER RD COUNTY PROPERTY El ® N DOORING ❑Y #OF MOTOR 0 SLOW 99 Cl) ❑ Kane 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 0 PED ❑PEDAL 0 EWES 0 NW 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 FOR DAMAGEDAREA(S) FRONT TOWED U1 0 Unknown.0. / ! Honda HR-V 00-NONE ©, 12 , DUE TO CRASH ❑ VI E NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 10.I !�. 2 FIRE 0 IE < STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED U2 9 3 SYSTEM IN O ENGAGED 0 15-OTHER 916-TOP 3 0 ' _ ❑Y ®N ❑UNK VEH. ATCRASH 99-UNKNOWN `Distraction Value g ALGN r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 i�6 �i 4 COM VEH 0 0 1 0 Z 0 9 0 EY97478 IL L REAR FIRST CONTACT 11 7_; __5 *lI Yes.See Sidebar U1 TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1) 3CZRZ1 H33SM714734 unknown ❑Y 0 N U2 m in 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 RESPONDER D Refused 0 Y ® N 99 0 g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑row 0 i v ❑Dv /1 9 yr 5 Dodge Caravan(inc Grand)2018 00-NONE ,�_` t2 "_, DUE TO CRASH ❑ ® 99 xi 0 13-UNDER CARRIAGE �) 2 FIRE ❑ ® U2 C c F 2 3 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `0istrac on Value g 9 POINT OF 6-i1 �i COM VEH ❑ ® U1 co N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 10 7 B -5 •IrYes,See Sidebar = PINGREE GROVEZ IL 60140 0 1 0 AT79506 IL REAR c 9 IL 0 2C4RDGCG4JR135874 Statefarm Insurance ❑Y ❑N RDEF X EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Same 1977728-SFP-13 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 < Refused RESPONDER®N U1 = (UNIT( (SEAT( (DORM (SEX) {SAFT) (AIR) (INJ) (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) W 04 / ' D / / 1 0 EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 11 1 02,28 /2025 10 25 ®PM in a Work Zone? ®N DIRP co 1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 � 2 0 04 15 N 3 ❑ ❑CITATIONS ISSUED 0 PENDING 1 1 ❑PM, ❑Construction SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM 0 Maintenance U2 -a, ARREST NAME / / ID PM ' o u ® 11 1 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT 30 t 2 0 ARREST NAME AM T 1 / ❑❑PM 0 Unknown work zone type U1 n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 30 1551 Dede.Joseph 501 391-Jacobucci r / ❑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 -< i- }---_r----; combination):or lb » ) INDICATE NORTH p3 I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C rrxar.�a! _ (example:shuttle or charter bus):or X rm r� 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 < } -A- - 1 ` } } } transporting employees in the course of their employment(example:employee transporter-usually a van type vehicle or passenger car):or w L L.___a__ 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including C} } for direct compensation(example:large van used for specificpurpose):or [he driver, 1 Pe ( P 9 Pe Aha i t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires a placarding(example:placards will be isplayed on the vehicle). XI igi - ADDRESS CARRIER NAME Z 0 l CITY/STATE/ZIP 0 I MOTOR CARR.ID 0 Interstate ❑ Intrastate 0 1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other i- --- --1 - 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 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 White u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO: _ . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 DUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE