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HomeMy WebLinkAbout2025-00019369 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets _ 01111101111 101101100 Hill I fl VOl 00 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00376 13 u, 1 U21 2 4 1 U, 5 U2 1 U, 1 1_12 1 U, 1 U2 1 1 10 U1 3 U211 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S 0$501-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ❑OVER 51,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 2025512025-00019369 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 71 TUMBLEWEED WAY El In03:02 ® ❑ RELATED ®Y 0 N 03 27 2025 ❑AM ❑YES ®NO U1 —< g PRIVATE mo !day/yr ®PM FLOW CONDITION m FT N E S W SILVERSPRING DR COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (/)❑ Kane HIT ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 -I ® &RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0 Qg3 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑NW ❑!CV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 n FOR DAMAGEDAREA(S) FRONT TOWED U1 Q Velsh. I na.V. 0 7 / yr 13-UNDER CARRIAGE ©i FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O " 2 DISTRACTED 0 0 U2 0 m F 2 SYTM 4 ❑Y ®SNE❑UNK VEH. O ATCRASHD 0 99-U 15-UNKNOWN THER O9 16•TOP 3 `Distraction Value ALGN X. r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6,_iL 6 4 COM VEH 0 j$J 1 0 ~ ELGIN N I L 60124 0 1 0 FIRST CONTACT 10 7 ; _5 *Irves.See Sidebar U1 Z BB99747 IL 2025 REAR TELEPHONE IL D 0 STDDZRFH3JS804249 State Farm ❑Y ®N U2 I ' in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same 1482259SFP13 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ® N 2 0 m g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 m v 0 i v 0 Dv CIRCLE NUMBER(S) U1 !1 9 yf 5 Honda Accord 2003 00-NONE 0.,. 2 j--O DUE TO CRASH ❑ 2 x 0 13-UNDER CARRIAGE 6 I ©Ic 2 FIRE ❑ ® U2 C c F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istraellon Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s-it 6 I:,-4 COM VEH ❑ ® U1 CO FIRST CONTACT 10 7�_, .5 •(ryes,See Sidebar = ELGIN IL 60124 0 1 0 P156978 IL 2025 RFJ 0 IL D 0 1 HGCM563X3A002130 State Farm ❑Y 123 N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Same 1079388SFP13 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER U1 = (UNIT) (SEAT) (DOB( (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) UI 2 m / 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 4 03/27 /2025 03 02 ®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 ,, Si 2 0 06 28 N 3 0 ❑CITATIONS ISSUED 0 PENDING ( 1 - ❑PM• ❑Construction SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 7 —a, u ARREST NAME / / ID PM ' 1 ® 11 4 0 CITATIONS ISSUED ❑PENDING UtilitySLMT o SECTION CITATION NO. ROAD CLEARANCE TIME El 0 AM t 2 ElARREST NAME 03/27 /2025 03 40 ®PM 0 Unknown work zone type U1 30 n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ ❑AM Workers present? ❑Y 30 488-Ramos.Arely 801 391-Jacobucci / / ❑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 m 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< i- ;.--__r-_--; i combination):or INDICATE NORTH p1 N BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C I _ (example:shuttle or charter bus):or X Q 3. Is designed to carry15 or fewer passengers and operated a contract carrier 0 L L.___A.._.� c _ y } } } transportingemployees In the course of their employment (example:employee e 1oii I- • 1 transporter-usually a van type vehicle or passenger car):or w L L.___a.._..l - 4. Is used ordesi natedtotrans rtbetween9and15 ssen rs,indudingthedrrver, O gis I } } } } for direct compensation(example:large van used for specific purpose):or L rr .� � l. l l 1 L 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires -u pMcartling(example:placards will be displayed on the vehicle). m CARRIER NAME Z _ __ ADDRESS 'O V) C) CITY/STATE/ZIP g Not To Scale 1 - MOTOR CARR.ID 0 Interstate El Intrastate O I r ❑ Not in Comm./Govt. 0 Not in Comm./Other ; _Y_ _-1 - USDOT NO. ILCC NO. m XI Source of above z . Were HAZMAT placards on vehicle? 0 Yes 0 No = If Yes,Name on placard O 4 digit UN NO. 1 digit Hazard class No. XI XI 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 g D Did Carrier Safety Regulations(MCS)violation contribute to the crash? A ❑ Yes I 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 71 IDOT PERMIT NO. WIDELOAD? ❑Yes 0 No 2 TRAILER VIM 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 1-1 TRAILER 2 ❑ 0 0 o u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w White Blue u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 2 TOWED BY/TO. SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® DISABLING DAMAGE Other/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE