HomeMy WebLinkAbout2025-00016605 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 4 Sheets 01111101111 I01101100
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003755E42
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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 ®5501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 2025I 2025-00016605 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
SUMMIT ST Elgin08:48
® ❑ RELATED ®Y 0 N 03 14 2025 12,— ❑YES ®NO U1 —<
_ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION Ill
FT N E S W DUNDEEAVE COUNTY PROPERTY El ® N DOORING ❑Y #OF MOTOR 0 SLOW 3 (n
❑ Kane 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
Qg3 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 n
FOR DAMAGEDAREA(S) FRONT TOWED U1 Q
NAME(LAST,FIRST,M) Unknown.O. mo ! / yr Unknown Unknown 00-NONE „ O i-, DUE TO CRASH ❑
EN
13-UNDER CARRIAGE 10 ' 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED U2 4 <
O ENGAGED 0 15-OTHER 9 76.TOP 3 ❑ _
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 9 ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s ;il 6 4 COM VEH 0 Ea 1 0
~ 0 1 FIRST CONTACT 12 7_; __5 *IIYes.SeeSidebar U1
Z UNKNOWN ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 11/
0 UNKNOWN UNKNOWN ❑Y ❑N U2 Rr1
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same UNKNOWN 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
r D Y°N0DER N X
m N DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NuV 0 i v 0 Dv
!1 9 8 7 Toyota Sienna 2013 00-NONE +i_-1 12..-_, DUETO CRASH ❑ C 2 73
o 13-UNDERCARRIAGE 10;1 2 FIRE ❑ ® U2 C
Ti
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP
3 X
❑Y NJ N DUNK VEH. AT CRASH 99-UNKNOWN `0istraebon Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8_iII 6 1,,_4 COM VEH ❑ ® U1 CO
FIRST CONTACT 6 Y__{_O ._5 •If Yes.See Sidebar Z SOUTH ELGIN IL 60177 0 1 0 Z570401 IL 2025 REAR
M
IL D 0 5TDKK3DC3DS294215 STATE FARM ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 1128090SFP13 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND O N U1 =
(UNIT) (SEAT) (DOB1 (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(A.DDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
2 6 12 /
2 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
u 1 El 11 1 3/ ,4/ ,025 08 48 ®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
ci, 2 0 28 99
N 3 0 0 CITATIONS ISSUED 0 PENDING + ! - 0 PM- ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 5
—a, ARREST NAME / / 0 PM
o U 1 ® 11 10 0 UtilityCITATIONS ISSUED PENDINGSLMT
o N SECTION CITATION NO. ROAD CLEARANCE TIME
r 2 0 11 1 ARREST NAME 3/ )4/ 1025 08 48 ®PM 0 Unknown work zone type U1 El AM 45
, T
OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ ❑AM Workers present? ❑Y 45
456-Romalo.Carmine 102 - 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••--, , ourxe, A CMV is defined as any motor vehicle used to transport passengers or property and: Z
i••____r____; I _ 1. Hasor more than pounds(example:truck or truck/trailer
1. Hasa weight rating10 000 i
-
c> INDICATE NORTH combination): -<
I! I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
(example:shuttle or charter bus):or 0
designed to carry 15 or fewer passengers and operated a contract carrier O
-- I - . - . transporting employees In the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
L L.___a__._J !":AY - 4. Is used ordesi nated to trans rt between 9 and 15passengers,includingthedriver, C
I I � I I r } } i- for direct compensation(example:large van used for speific purose):or 0
L -a-___.I - l. i i i. i. 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). ;p
euarzrrsr CARRIER NAME Z
— — — — — ADDRESS
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CITY/STATE/ZIP
[I g
Not To Scale I MOTOR CARR.ID 0 Interstate 0 Intrastate
I ❑ Not in Comm./Govt. ❑ Not in Comm./Other 00
1 I . , , , C
USDOT NO. ILCC NO. m
XI
Source of above 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
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
ill
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Green Black
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ElNOT DISABLING DAMAGE DAMAGE EXTENT' 9 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