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HomeMy WebLinkAbout2025-00014802 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100 IVOl 11111111 I DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X0037.56589- u, 1 U21 1 1 3 U1 9 U2 1 U1 1 U2 1 U1 1 U2 1 1 10 U,23 U2 -3-1 *P0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El5501-51.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) (83B Injury and for Tow Due To Crash 0 AMENDED YR 202512025-00014802 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 m® ❑ RELATED PRIVATE ❑Y ®N 03 07 2025 ❑AM ❑YES ®NO U1 -< W HIGHLAND AVE Elgin mo /day/yr 12:05 ®PM FLOW CONDITION m ®150 /MI N E S © Woodland Ave COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 15 u) Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I 0 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 NOV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 n 0 6 FOR DAMAGEDAREA(S) FROPtf TOWED U1 O NAME(LAST,FIRST,M) Schaumback.Sofia.A. mo Chevrolet Traverse 2022 00-NONE DUE TO CRASH 0/ , yr 11.. 12 EN E 13-UNDER CARRIAGE 10l 2 FIRE 0 IE •STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 3 <<T1 F 2 SY4 ❑Y ®SNEM❑UNK VEH. 0 AT CRASHIN 0 15-OTHER 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF a iII a ii,4 COM VEH 0 Ea 1 0 ~ ELGIN IL 60123 0 1 0 FIRST CONTACT 6 7_;LQ__5 *IIYes.See Sidebar U1 Z DF12391 IL 2025 mai TELEPHONE IL D 0 1 G N ERFKW7NJ 149417 Progressive Ins ❑Y Il N U2 1- in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR Schaumback.Jack 934747015 2 m `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 p; DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑iiuv 0 Ncv ❑DV yrr 1 9 yr 6 Chevrolet Equinox 2022 00-NONE ,�"j Qr , DUE TO CRASH 0 (� 2 0 13-UNDER CARRIAGE 10( I 2 FIRE 0 ® U2 C c F 2 5 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X ❑Y 181 N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distract on Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s FIRST CONTACT 12 7�-il 6 I:,1.5 4 CO• (Iv le VEH See Sidebar❑ ® U1 CO_, II". ELGIN IL 60123 B 1 0 DQ12426 IL 2025 REAR 0 C IL D 0 3G NAXH EG9PL157728 Progressive Ins ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Elgin Fire Same 964974325 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPOND O N U1 = (UNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z u 1 ® 11 1 03,07 ,2025 12 05 ®pm in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 4 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 Eri 2 0 30 99 03,07 ,2025PM N 1 3 0 0 CITATIONS ISSUED 0 PENDING 0 ❑Construction >F SECTION CITATION NO. EMS ARRIVED TIME 8 ❑AM 0 Maintenance U2 -a, ARREST NAME / / _ El PM ' 1 ® 1 1 1 ❑CITATIONS ISSUED ❑PENDING - • UtilitySLMT oN SECTION CITATION NO. ROAD CLEARANCE TIME 0 r 2 El ARREST NAME 03107 i2025 12 24 ®PM El Unknown work zone type U1 30 0 AM n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? 0 Y 30 254 Henke. Robert 607 393-Gutierrez , / ❑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 ` --1 -' r INDICATE NORTH combination):or —I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver n } ® - } (example:shuttle or charter bus):or C ti 3. Is desgnetl to carry 15 or fewer passengers and operated a contract carrier O — - -----A----i } } } transporting employees In the course of their employment(example:employee t transporter-usually a van type vehicle or passenger car):or w L }-----}----l. r, - } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver. N 1 � for direct compensation(example:large van used for specific purpose):or O ' a L i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example:placards will be displayed on the vehicle). —I -� - CARRIER NAME Z " ADDRESS 0 V) Not To Scala Ii. i. i. i. 4. 0 CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate 0 Intrastate . I . . ❑ Not in Comm./Govt. 0 Not in Comm./Other -----------1 - USDOT NO. ILCC NO. rn XI Source of above Z . • m 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 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 Xl IDOT PERMIT NO. WIDELOAD'; 0 Yes 0 No 2 TRAILER VIN 1 m co LOCAL USE ONLY TRAILER VIN 2 m v TRAILER WIDTH(S) 0-96" 97-102" >102' m TRAILER 1 0 0 0 Z ill TRAILER 2 ❑ 0 ❑ O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Black White u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ElNOT 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: 3 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE