HomeMy WebLinkAbout2025-00017378 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003 65414
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TWO/ '
Elgin Police Department ONE PERSON'S 1215501-$1.500 ❑ON SCENE 15
VEHICLE/PROPERTY ❑OVER$1,500 ®NOT ON SCENE(DESK REPORT)
❑AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00017378 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
BIG TIMBER RD El In12:45
® ❑ RELATED ❑Y ®N 03 12 2025 DAM ❑YES ®NO U1 -<
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W N STATE ST COUNTY PROPERTY El PROPERTY ® N DOORING ❑y #OF MOTOR 0 SLOW 15 Co
❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD ® STOPPED U2 --I
lgi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PEO 0 PEDAL 0 EWES 0 NIAV 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
FOR DAMAGEDAREA(S) F000fr TOWED U1 Q
NAME(LAST,FIRST,M) unknown mo 1 yr Chevrolet Malibu 2023 00-NONE „ Oi_, DUE TOCRASH ❑
EN
13-UNDER CARRIAGE 10 , 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED U2 4 <
g ENGAGED 9 15-OTHER 9 16.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 0 1
Z0 9 0 EK68782 I L FIRST CONTACT 12 7 ; 5_ *uYes.See Sidebar U1 0
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1/
1 G 1 ZD5ST4PF152010 NIA 0 v 0 N U2 1-
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Campbell.Takara. D. NIA 1 rn
`5 HOSPITAL(TAKEN TO) INCIDENT IF'V OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
99
m g DRIVER ❑ PARKED 0 DRIVERLESS 0 PEO 0 PEDAL 0 EWES 0 MAv 0 KCV 0 Dv CIRCLE NUMBER(S) U1
9 yf 4 Ford Escape 2021 00-NONE 1 t2 c,�2 FIRE DUE O CRASH 0 ® U2 2 C
o 13-UNDER CARRIAGE
c
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3
❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN `0istrac on Value g g
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 - 6 i1,'-4 COM VEH ❑ ® U1 CO
FIRST CONTACT 5 7 _,SOS •If Yes.See Sidebar
Z Carol Stream IL 60188 0 1 0 ALFY616 IL REAR e
0 cn
M
IL 1 FMCUOG64MUA69067 State Farm ❑Y J N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 0553346-sfp-13 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND 0 N U1 =
(UNIT) (SEAT) (DOS) (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 0 Y U2 Z
N 1 ® 11 1 31 (81 )025 05 26 ®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 ❑ 15 03
N 3 ❑ 0 CITATIONS ISSUED 0 PENDING ( 1 ❑PM• ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 3
-a, ARREST NAME / / ❑PM
o N El 1 •
0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility
SLMT
r 2 ❑ 45
ARREST NAME AM
7 ( / ❑❑PM ❑Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ° 560-Martirez.Samantha 501 391-Jacobucci ( / ❑❑PM Workers present? ®N U2 45
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
i I I 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O
}. -A- --i `
I I I' } 1. transporting employees in the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or w
L I I. 4. Is used or designated to transport between 9 and 15 passengers,including C}--- ----; - I. } } g po passen rs,includi the driver,
. for direct compensation(example:large van used for specific purpose):or
L L--_-a-....I I 0 - 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). X/
l l CARRIER NAME Z
ADDRESS 0
T.Not To Scale I
CITY/STATE/ZIP 0
0
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other
; _Y_ __; - USDOT NO. ILCC NO. m
XI
Source of above z
. 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 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
White Gray
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: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE