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HomeMy WebLinkAbout2025-00014260 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111 I01101100 I011101 MO 0 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003749229 u, 9 U21 1 1 2 U1 2 U2 1 U,99 1_12 1 U1 99 U2 1 5 12 u, 1 U2 1 *P 0119 INVESTIGATING AGENCY DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW ' Elgin Police Department ONE PERSON'S 0$501-$1.500 ®ON SCENE 11 VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00014260 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 —n RT20 El ❑ RELATED ❑Y ®N 03 05 2025 00:17 E�IAM ❑YES ®NO U1 Elgin PRIVATE mo /day/yr ❑PM FLOW CONDITION m ®70�F !MI N E S © Shales St COUNTY PROPERTY ElY ® N DOORING El #OF MOTOR 0 SLOW 2 Co 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 18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0 / / FOR DAMAGEDAREA(S) FROM TOWED U1 Q Unknown.0. Other Other 00-NONE ,, 12 0DUE TO CRASH 0EN NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 101 1!O 2 FIRE 0 ® < STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0U2 m 9 9 Y ❑N ❑UNK VEH.SYSTEM IN ❑ ENGAGED AT CRASH 15-OTHER 99-UNKNOWN 9 76.70P�3 *Detraction Value _ ALGN r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 1 6_iL 6 ii,4 COM VEH ❑ El 1 I— 0 9 FIRST CONTACT 7_;I -5 *II Yes.See&debar Ut 0 2 Z ' E TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1/ 37396 unkown ❑Y ❑N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m co Same unknown 2 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V OWNER STREET,CITY,STATE,ZIP PHONE NUMBER r D Y°N❑l N m N DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES 0 M/V 0 t v 0 Dv /1 9 6 4 y yr Dodge Ram 1500(pickup) 2016 00-NONE O,' t2 "_, DUE TO CRASH ❑ 2 0 13-UNDER CARRIAGE 10 I 2 FIRE ❑ ® U2 C c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 ❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN `OistractIon value 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-it 6 11:, 4 COM VEH D ® U1 CO FIRST CONTACT 11 7�� _,__5 •If Yes.See Sidebar H E LG I N IL 60120 0 1 0 3311425B IL 2025 REAR 0 N IL 7 1C6RR7HTXGS317861 Allstate ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same 811050230 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)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 11 9 03/05 /2025 00 17 ®❑pM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 � Oi 2 ❑ 04 18 N 3 ❑ ❑CITATIONS ISSUED 0 PENDING + / ❑PM• El Construction SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 3 —a, ARREST NAME / / El PM ' oN 1 ® 11 1 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT t 2 ❑ ARREST NAME AM 7 / / ❑❑PM ❑Unknown work zone type U1 n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ 1553-Jentsch.Clarissa 300 391-Jacobucci / / ❑❑PM Workers present? ®N U2 50 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 ` --I -' r INDICATE NORTH combination):or .Z-1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C _ } (example:shuttle or charter bus):or X Not 7b Seeks f 3. Is designed to carry 15 or fewer passengers and operated a contract carrier 0 I- }-----I--•-•i �� \ r� N - i. } } } transportingemployees in the course of their employment pbyntent(example:employee or X C i. ...l. ' 1 1 4.transporter �sedordsignatedtotranslly a van type portbetweeicle or n9a d15enger rpassen rs,includingthedriver. N } } } for direct compensation(example:large van used for specific purpose):or L L____a____� A L L 5 Isanyvehcleusedtotransportanyhazardousmateral(HAZMAT)thatrequires m 2:.> placarding(example:placards will be displayed on the vehicle). XI —1 CARRIER NAME Z ._ ADDRESS 0 C) CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate 0 Intrastate 0 I r ❑ Not in Comm./Govt. 0 Not in Comm./Other --- --1 - USDOT NO. ILCC NO. m XI Source of above z . 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 Gray 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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO. DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE