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HomeMy WebLinkAbout2025-00019886 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100 0 00 1111 111E11 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003/71363 u1 1 U2 1 1 1 U1 1 U2 U1 1 U2 U1 1 U2 4 4 U1 1 U2 *P 9* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ❑OVER 51,500 El NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and f or Tow Due To Crash YR 2025512025-00019886 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 '1 ® ❑ RELATED PRIVATE ❑Y ®N 03 29 2025DAM ❑YES ®NO U1 -< W HIGHLAND AVE Elgin mo /day/yr 07:52 ®PM FLOW CONDITION m ®7 FT/® NOS w McCornack Rd COUNTY PROPERTY ❑Y ® N DOORING El #OF MOTOR 0 SLOW fA Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 02 n _ 0 8 / yr 13-UNDER CARRIAGE © 4!. Z FIRE 0 ® E STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O O DISTRACTED 0 0 U2 m M 2 4 SY 15-OTHER ❑Y ®N SE❑UNK VEH. 0 AT CRASM IN H 0 99-UNKNOWN 9 16•TIDP 3 `Distraction Value 9 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s_iL a 4 COIN VEH 0 j$J 1 O H 1- PINGREE GROVE IL 60140 0 1 0 FIRST CONTACT 12 r : __s 'If Yes.See Sidebar u1 Z DY98712 IL 2025 E TELEPHONE IL D 3VW4S7AJ4DM300040 Allstate ❑v ®N U2 �r— in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Heinz!.Amy 975907585 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 73 rg- ❑ DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 iiuv 0 i v 0 DV yr 12 _ X1 o 13-UNDER CARRIAGE ��.i :., FIRE 0 ❑ U2 C c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 0 ❑ SPDR n 0 Y ❑N 0 UNK VEH. AT CRASH 99-UNKNOWN `Oistraellon Value U1 0 - POINT OF s-.;, 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT Y�='+.:-4 C•IO e1sVEH SeeSidebar❑ 0 C CO I� pEAR` C M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O ❑Y ❑N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = BAC HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < RESP❑YO❑N NDER U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) n / / U2 r m / / ##occs > / / UI 1 D 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 15 1 Department of Natural Resources Deer was hit 31 1 91 /025 07 52 ®AM 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 � ;, t 2 0 1 NATURAL RESOURCES WA'pringfieldL 62702 21 99 r , 0 PM ❑Construction * ZJ 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 ARREST NAME / / ❑PM ' 10o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT 45 t 2 ARREST NAME AM ! 1 ❑❑PM ❑Unknown work zone type U1 El 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y 2 3 0 - ❑AM Workers present? ❑ 1506-Nunez. Maria 901 ! / ❑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. A CMV is defined asmotor vehicle used to transportand: r ----,5-••--, ; any passengers or property Z 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< } i.-- -i-- --; } } } r -, , ; ; , ; ( INDICATE NORTH combination):or —I p1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } ' i 1 , } (example:shuttle or charter bus):or X 3. Is L L.___A_. 1 <--_- -___� J transporting employened to es Inhecourse 5 or fewer o their eers mplod yment example:employeener X } } } transporter-usually a van type vehicle or passenger car):or c0 < <.__-a-_-_, , l• < <--_-a-___� , , , , 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or 0 L L___-a____.: L L L i.___-..:_____� l. i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example:placards will be displayed on the vehicle). XI --I CARRIER NAME Z ADDRESS 0 u) CITY/STATE/ZIP MOTOR CARR.ID 0 Interstate ❑ Intrastate 0 ❑ Not in Comm./Govt. ❑ Not in Comm./Other O USDOT NO. ILCC NO. m XI Source of above z . —I Were HAZMAT placards on vehicle? 0 Yes 0 No = If Yes,Name on placard O 4 digit UN NO. 1 digit Hazard class No. Xl Xl 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? ❑ Yes II No ElUnknown 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 v TRAILER WIDTH(S) 0-96" 97-102" >102' m TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U_COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Silver 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_TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO.DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE