HomeMy WebLinkAbout2025-00017065 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100 00 01
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ❑ON SCENE 7
VEHICLE/PROPERTY El OVER$1,500
®NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and f or Tow Due To Crash YR 202512025-00017065 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 7 '1
825 TOLLGATE RD Elgin06:45
® ❑ RELATED 0 Y ®N 03 17 2025 ®AM ID YES ®NO U1 —<
_ g PRIVATE mo /day/yr ❑PM FLOW CONDITION MCOUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR 0 SLOW 3 Cl)
❑ FT/MI NESW Cook HIT&RUN ®Y ❑ N WITH VEHICLES INVLD ® STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Q83 DRIVER O PARKED O DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
0 7 !
yr 13-UNDER CARRIAGE 101 ! 2 FIRE 0 IE <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 m
M 2 9 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 _
❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 16 4 COM VEH ❑ Ea 1
H F.
Philadelphia PA 19116 0 1 C490683 ME FIRST CONTACT 99 7_;Ismi
_s Yes.See Sidebar U1 0
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TELEPHONE
PA 4V4NC9EH9PN609699 Acord ❑Y ❑N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
AFS World 302501-9572447Y 9 r
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER
99
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p DRIVER X. PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0
� !1 9 8 9 Chevrolet Equinox 00-NONE 1("j 12..-_t DUETO CRASH ❑ 2 73
o 13-UNDER CARRIAGE 10 1 2 FIRE ❑ ® U2 C
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F 9 9 SYSTEM IN ENGAGED 15-OTHER 9 16•TOP 3 0 X
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S_iII 6 I,,_4 COM VEH D ® ut CO
FIRST CONTACT 6 Y__{_O ._5 •IfYes.SeeSidebar
n ELGIN IL 60123 0 BL52698 IL REAR C
0
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IL 2G NAXJ EV4J6108177 State Farm ❑Y ❑N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 99 =
Same 1035450SFP13 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
RESPOND❑Y0N u1 =
Y
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 18 1 03!17 /2025 10 20 ®❑PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 30
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 ❑ 18 18
N 1 3 ❑ 0 CITATIONS ISSUED 0 PENDING + ! ❑PM ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 3
z
—a, ARREST NAME / / ❑PM '
o u El 11 1 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT
10
T 2 D ARREST NAME AM
7 ! ! ❑❑PM ❑Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ID ❑AM Workers present? D Y 10
562-Hernaindez. Myra 331-Ziegler ! ! ❑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 -<
` ` --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
Not:lb Scala l - } (example:shuttle or charter bus):or C)
X
L A 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
transporter-usually a van type vehicle or passenger car):or w
< •<. i
I. } } 1 •4. Is used or designated to transport between 9 and 15 passengers,including the driver. N
for direct compensation(example:large van used for specific purpose):or O
L L--_-a-....I ,.` - t 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
—1
CARRIER NAME Z
ADDRESS 0
V
C)
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
-"-----"1 - USDOT NO. ILCC NO. m
XI
Source of above z
. 0 Yes 0 No ❑ Unknown 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-; ❑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
White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 9 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/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE