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HomeMy WebLinkAbout2025-00014162 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I01101100 III IIII I IIIIIIIIII DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003749235 u, 1 U21 3 4 2 U1 2 U2 1 u,99 U2 1 u, 1 U2 1 1 10 u, 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 8 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00014162 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 71 BIG TIMBER RD El In 01:20 ® ❑ RELATED ®Y 0 N 03 04 2025 ❑AM ❑YES IX]NO U1 -< g PRIVATE mo !day!yr ®PM FLOW CONDITION m FT!MI N E S W N RANDALL RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLESOT, INVLD 00 STOPPED U2 -I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EOUES 0 UUV 0!CV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 n 0 6 ! yr Chevrolet Traverse 2011 00-NONEEN 13-UNDER CARRIAGE ©I O - DUE TO CRASH ❑FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 2 DISTRACTED ❑ 0 U2 0 m F 2 SY4 ❑Y ❑SNEM®UNK VEH. 9 AT CRASH IN 9 15-OTHER 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 7 it 6 ii,4 COM VEH 0 j$J 1 0 H F. Elgin IL 60124 0 1 0 FIRST CONTACT 11 7_;1 __-5 *IKYes.SeeSidebar U1 Z 91872858 IL 2025 REAR TELEPHONE IL D 1 G N KRG ED9BJ408794 State Farm ❑Y Il N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m co Same 0245263SFP13 2 m "o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER t RESPONDER 0 N DRIVER 0 PARKED 0 DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 r vv 0 KKv 0 Dv CIRCLE NUMBER(S) U1 !1 9 9 9 Toyota Camry 2000' 00-NONE 10' t2 c,�2 FIRE DUE O CRASH 0 ® U2 2 73 C o Yr 13-UNDER CARRIAGE c F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 911,6•TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `0istraetlon Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 0'i- 6 il;, 4 COM VEH ❑ ® U1 CO C FIRST CONTACT 8 QJ__,�_-5 *If Yes.See Sidebar Roselle IL 60172 0 1 0 BR90534 IL 2025 F 0 fp Z D IL 4T1 BF28K4YU952542 Allstate ❑Y ®N RDEF X EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Petragallo.Antonio 811895863 SAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP u1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 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 31 r 12 !25 01 20 ®PM AM in a Work Zone? ®N DIRP co 1 F PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 6 n T o" 2 0 2 18 1 r ❑PM• 0 Construction * Z3 0 1!>I CITATIONS ISSUED El PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 3 o1 ® 11 4 ARREST NAME Johnson.Constance. M. 11-305 410000705 / ! El PM SLMT o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility 45 F 2 0 ARREST NAME AM T r r ❑❑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 45 410-DeLeon.Jessica 502 272-Bajak r 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 -< c ` -- -' r INDICATE NORTH combination):or .Z-1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C i_ w'-" - } (example:shuttle or charter bus):or 0 tV J I I I I I I _ ,I 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 aum,mrwb transporter-usually a van type vehicle or passenger car):or w 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 0 L L--_-a-___. j j - t i. i L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires III , _ _ _ _ r r r placarding(example:placards will be displayed on the vehicle). XI {p s` D ) — U CARRIER NAME Z ._ ADDRESS 0Iiiiiir v) CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate ❑ Intrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other ------- --1 - USDOT NO. ILCC NO. rn XI Source of above z . IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No = TRAILER VIN 1 m co LOCAL USE ONLY TRAILER VIN 2 m 0 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 Beige Beige 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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE