HomeMy WebLinkAbout2025-00014816 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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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 El$501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00014816 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
CANTERBURY CT Elgin 01:31
® ❑ RELATED ®Y 0 N 03 07 2025 ❑AM ❑YES ®NO U1 -<
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION MFT!MI N E S W WOODVIEW CIR COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 15 u)
❑ Cook HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 -I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
0 9 /
yr
Kia Motors Cotjtptima 2019 00-NONE it , OUETOCRASH ❑ EN
13-UNDER CARRIAGE 16 i 12•y 2 FIRE 0 IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 M
F 2 4 ❑Y SYSTEM IN ENGAGED 0 15-OTHER 9 16.TOP
�3 * 9 ALGN =
❑N ❑UNK VEH. AT CRASH 99-UNKNOWN Distraction Value
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6_iL 6 if._4 COM VEH 0 j$J 1 0
~ ELGIN I L 60120 0 1 0 FIRST CONTACT 3 7_: __5 *II Yes.See Sidebar U1
Z CZ33830 IL 2025 REAR
TELEPHONE
IL D 0 5XXGT4L3XKG295645 State Farm ❑Y Il N U2 93 . m
B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Other 1 99 9 Same 0098022sfp13 2 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 3 2 0
m x DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑iiuv 0 i v ❑DV
yr 13-UNDER CARRIAGE 10( ) FIRE ❑ ® U2 C
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-it 6 11:,-4 COM VEH D ® U1 to
FIRST CONTACT 12 7�RFJ , .5 •(ryes.See Sidebar
= ELGIN
M I L 60120 0 1 0 D P83605 I L 2025
IL D 0 1 C4NJPFB5ED790125 Farmers Ins ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Other 1 99 9 Same 184505310 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER 0 3 U1 =
(UNIT) (SEAT) (DOB1 (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
2 3 11 / M 2 4 0 1
m
/ / #OCCS D
71
/ / U1 1 D
/ / 2 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 4 31 r 12 /25 01 31 ®PM AM in a Work Zone? ®N DIRP D
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1 t PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 3 C1
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2 ❑ 2 18 I I 0 PM• El Construction *
R 3 ❑ 1!>I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
a1 ® 11 4 ARREST NAME Cruz,Yesenia 11-901-A 324-(W)1443 / I El PM SLMT
o N •
0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility
30
r 2 ARREST NAME AM
T El r ❑❑PM ❑Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ - ❑AM Workers present? ❑Y 30
324-Phillos.James 302 , I ❑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
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1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
} i.-- -i-- --; } } } r -, , ; ; , 1, ( INDICATE NORTH combination):or —I
71
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
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3. Is
. L.___A_. 1 ..._... . J transporting edmployeeslIn5 hecourseeo theire rsmployment exam pal
e:employeener 73} } }
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 ...._-..:_____� 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). m,Zt
--I
CARRIER NAME Z
ADDRESS 0
T.
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
.
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
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LOCAL USE ONLY TRAILER VIN 2 m
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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
Gray 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: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE