HomeMy WebLinkAbout2025-00017462 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100 III100111111
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003762189'
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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 El$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00017462 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 16
® ❑ RELATED ❑Y ®N 03 19 2025 ®AM ❑YES ®NO U1 -<
ROUTE 20 HWY Elgin07:56
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
0 !MI N E SWest Ridge Dr COUNTY PROPERTY ❑Y ® N DOORING ❑V #OF MOTOR ®SLOW 15 Co
® ® g Kane HIT&RUN ❑V ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 NIAV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FOR DAMAGEDAREA(S) FRO T TOWED U1 Q
Da Justin.S. 0 2 /
yr 13-UNDER CARRIAGE fa:) 2 ' 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® ❑ U2 2 m
M 2 4 Y SYSTEM IN ENGAGED 15-OTHER 9 76.TOP 3 5 ALGN =
❑ ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Vatuc
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 ::il 6 _s 4 Yes.See Sidebar Ut COM VEH 0 j$J 1
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H 1 FIRST CONTACT 12 Y
ELGIN I N I L 60124 0 1 0 FP254358 I L
Z E
TELEPHONE
IL C 3C7WRKAJ6PG520327 Ace American ❑v ®N U2 M
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Comcast Cable Commun ISAH11352637 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER >
Refused ❑Y ❑ N 3 1473
x DRIVER 0 PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0
!1 9 6 5 Acura M DX 2011 00-NONE ,._j t2..-_, DUE TO CRASH ❑ ! l 2 x
o yr 13-UNDERCARRIAGE 10;1 2 FIRE ❑ ® U2 C
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F 2 4 SYSTEM IN ENGAGED 15-OTHER 9 16•TOP 3 3
❑Y ❑N DUNK VEH. AT CRASH 99-UNKNOWN `Distraction Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8
iI 4 COM VEH 0 ® Ut CO- (Ai'_
FIRST CONTACT 6 Y__{_ ._5 •IfYes.SeeSidebar
I- PINGREE GROVE Z IL 60140 0 1 0 X557683 IL 2025 FIRST
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IL D 2HNYD2H27BH531391 Farmers ❑Y123 N RDEF73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same A7992159800 BAc E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND❑N 3 U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 1 31 (91 l025 07 56 ®❑PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
2 ❑ 28 41 ( ( 0 PM ❑Construction *
04
Z ' EMS ARRIVED TIME 3
3 ❑ ]�CITATIONS ISSUED El SECTION CITATION NO. ❑AM ❑Maintenance U2
-a, ARREST NAME Davy.Justin.S. 11-601 W298001216 ( ! ❑PM SLMT
oN ® 11 2 ElCITATIONS ISSUED ElPENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
T 2 0 ARREST NAME AM
7 ( 1 ❑❑PM 0 Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ ❑AM Workers present? ❑Y 50
298-Lopez, Mirko 801 - ( 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
1 ADDITIONAL UNITS FORMS.
r ----r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
W„tiNd,112,, 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
c ` --I -' r INDICATE NORTH combination):or —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
L 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
atransporter-usually a van type vehicle or passenger car):or co} } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver, N
4% for direct compensation(example:large van used for specific purpose):or O
L Not To Seale I l. i. < i. 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires III
placarding(example:placards will be displayed on the vehicle). m,Zt
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; : - CARRIER NAME Z
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ADDRESS0
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0
CITY/STATE/ZIP g
—11 MOTOR CARR.ID 0 Interstate El Intrastate
' Shannon?Pkwy. ❑ Not in Comm./Govt. ❑ Not in Comm./Other 00
------- --: - USDOT NO. ILCC NO. C
m
XI
Source of above Z
. ❑ Yes 0 No 0 Unknown M
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
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TRAILER WIDTH(S) 0-96" 97-102" >102' T
TRAILER 1 0 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
White 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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE