HomeMy WebLinkAbout2025-00013888 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II 1 III 11 II I1 II 11111111
1 DDI II
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003748597"
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500
El NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00013888 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
CONGDON AVE Elgin 03:21
® ❑ RELATED ❑Y ®N 03 03 2025 12,— ❑YES ®No u1 -<
PRIVATE mo /day/yr ®PM FLOW CONDITION RI
FT!MI N E S W TOASTMASTER DR COUNTY PROPERTY ❑Y ® N DOORING ICIy #OF MOTOR 0 SLOW 1 (n
❑ Cook HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Qg)DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 uuv 0 ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) y N 2 n
FOR DAMAGEDAREA(S) FRO T TOWED U1 O
DUNGEY.CHANDLER.A. 0 1 /
yr 13-UNDER CARRIAGE Cgl
10l !�. 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ga U2 2 rn
2 4 SYTM❑Y 0$NE❑UNK VEH. 0 AT CRASH 0 99-U 15- NKNOWN THER9 76•TOP® *Distraction Value ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ iI jl COM VEH 0 Ea 1 n
I.• FIRST CONTACT 3 7 _ 6--_;__5 *elves.See Sidebar U1 0
Z ELGIN IL 60123 0 1 0 N724037 IL T's
TELEPHONE
0 1 FA6P8CF6F5302740 Geico ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 4435672144 1 r
5HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
r RESPONDERN
yr
/1 9 8 3 Kia Motors Coilptima 2013 00-NONE „ " 12' , DUE TO CRASH ❑ (� 2
0 13-UNDER CARRIAGE FIRE ID ® U2C
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 016-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istraglon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF O) ;,.4 COM VEH ❑ ® tit CO
F„ FIRST CONTACT 11 7 _, _5 •If Yes.See Sidebar C
ELGIN IL 60120 0 1 0 CW48980 IL I:EaR 0 Si)M
0 KNAGM4AD4D5054421 Geico ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
Same 6029742027 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((A.DDRESS)((TELEPHONE) (EMS) (HOSPITAL)
2 6 10 /
2 O
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 El 11 1 03,03 /2025 03 27 ®pm in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 ,o
O 2 ❑ 04 28 / / ❑PM ❑Construction
Z 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
a DUNGEY.CHANDLER.A. 11-601 476000350 / / PM '
a u 1 ® 1 1 1 ARREST NAME ❑
j$!CITATIONS ISSUED 0 PENDING UtilitySLMT
o N SECTION CITATION NO. ROAD CLEARANCE TIME AM• ❑
T 2 0 ARREST NAME DU NG EY.CHANDLER.A. 11-402-A 476000349 03/03 /2025 04 18 ®PM ❑Unknown work zone type U1 30
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
476-Ramos.Clarissa 201 04 / 15/2025 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
0 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 truckrtrailer -<
` ` -' -' • INDICATE NORTH combination):or .Z-1
i 1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
(example:shuttle or charter bus):or 0
r r X
I- L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
} } } transporting employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or CO
L 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 O
wx
•p
L L--_-a____. I I I L 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
rn
ii placarding(example:placards will be displayed on the vehicle). XI
CARRIER NAME —I
conoon4lN.. 0
ADDRESS
w
n
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
USDOT NO. ILCC NO. m
Not To Scale j XI
Source of above z
. ❑ Yes II 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
to
LOCAL USE ONLY TRAILER VIN 2 m
0
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. w
Black Black
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: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE