HomeMy WebLinkAbout2025-00013813 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
I01101100 III IIIII 0100
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003748955
u, 1 U21 3 4 1 U1 7 U2 1 u, 1 1_12 1 U1 1 U2 1 1 11 U1 1 U211 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 3
VEHICLE/PROPERTY ®OVER 91,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 202512025-00013813 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 m® ❑ RELATED PRIVATE ®Y 0 N 03 03 2025 ®AM YES ®No u1 -<
DUNDEE AVE Elgin mo /day/yr 09:40 ❑PM FLOW CONDITION m
®1 0 ®!MI N E OS Vtr PAGE Ave COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
Kane HIT&RUN ❑V ® N WITH VEHICLESOT,
INVLD ® STOPPED U2 -I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS O
DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NOV 0!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0
FOR DAMAGEDAREA(S) FROrtf TOWED U1 Q
yr NAME(LAST,FIRST,M) Dismuke.Andrea.S. 0 mo 5 / 1 9 8 1 Dodge Journey 2019 00-NONE 1.,..' Qi�, DUE TOCRASH ® ❑
13-UNDER CARRIAGE 19 i : 2 FIRE 0 IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 23 U2 4 <<Tl
F 2 8 SY®Y ❑SNEM❑UNK VEH. 1 AT CRASH IN 1 15-OTHER
99-UNKNOWN 9 16•TOP 3 ,Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $_iL 6 4 COM VEH El Ea 1 0
ZFIRST CONTACT 12 Y _s Yes.See Sidebar Ut
E LG I N I L 60120 B 1 0 CS 18555 I L
TELEPHONE
IL 0 3C4PDCEG2KT783046 PROGRESSIVE ❑Y ®N U2 I''I
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 1 99 9 Same 966897023 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Provena St.Joseph ❑Y ® N 9 2 eu
m N DRIVER ❑ PARKED ❑DRIVERLESS ❑ PEO 0 PEDAL ❑EWES ❑
1 9 8 4 Dodge Challenger 2023 00-NONE 11_i t2 -_, DUE TO CRASH p 2
0 13-UNDER CARRIAGE to l 2 FIRE ® C)
0 ® U2 C
c
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X
❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistraellon Value 9 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S II 6 I,,_4 COM VEH ❑ ® tit CO
CONTACT 6 Y__{_0r-s •IfYes.See Sidebar
Z
CRYSTAL LAKE IL 60014 0 1 EY IL 2025aR
C
D
IL D 0 2C3CDZJG7PH565700 GEICO ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
1 99 9 Same 6152951668 BAc E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused E Y°®N 9 U1 =
;UNIT) ISEATI (DOB1 (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
1 4 09 / M 2 3 0 1 0
m
/ / #OCCS D
71
/ / UI 2 m
/ / 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 1 31 ,12 ,25 09 40 ®❑pM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1
2 ❑ 28 99 31 ,12 ,25 09 40 ❑PM ❑Construction
E
R O ❑ xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
3 ®AM ❑Maintenance U2
o ® 11 1 ARREST NAME Dismuke.Andrea.S. 11-601-Ax 374001303 31 ,12 /25 09 49 ❑pM SLMT
o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
AM U1 30
r 2 ❑ ARREST NAME 31 r 12 ,25 10 03 [M PM 0 Unknown work zone type
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 30
374-Rizzu-o. Michael 201 331-Ziegler 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.
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
combination):or -<
/ r INDICATE NORTH XJ/
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
I _ } (example:shuttle or charter bus):or
® / f 3. Is designed to car 15 or fewer passengers and operated a contract carrier O
._ / I - . - . transporting employees in the course of their employment(example:employee 73
transporter-usually a van type vehicle or passenger car):or CO
-- Not To Scale , I / ... - } } 1 •4. Is used or designated to transport between 9 and 15 passengers,including the driver. C
for direct compensation(example:large van used for specific purpose):or 0
i i t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
Alb' _ . t placarding(example:placards will be isplayed on the vehicle). XI
I N - _I
I ;,� r i - CARRIER NAME Z
• ADDRESS 'Z
.'
o
1 CITY/STATE/ZIP g
/ - i. MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I a„ ❑ Not in Comm./Govt. 0 Not in Comm./Other
----------1 - USDOT NO. ILCC NO. rn
XI
Source of above z
. ❑ Yes 0 No 0 Unknown M
D
Did Carrier Safety Regulations MCS)violation contribute to the crash?
❑ Yes II No ElUnknown 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
73
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIM 1 m
to
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. y
Black Black
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO.
_Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE