HomeMy WebLinkAbout2025-00020549 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 101101100 0011111100
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003 76326
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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 ❑$501-$1.500 ®ON SCENE 15
VEHICLE/PROPERTY ®OVER$1,500
El NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and/or Tow Due To Crash YR 2025I 2025-00020549 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 71
300 S MCLEAN BLVD Elgin04:14
® ❑ RELATED 0 Y ®N 04 01 2025 ❑AM ❑YES ®NO U1
_ g PRIVATE mo /day/yr ®PM FLOW CONDITION MCOUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR ®SLOW 3 Cl)
❑ FT/MI N E S W Kane 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 ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑Icy ❑ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) y N O C)
/
/ T FOR DAMAGEDAREA(S) FROM�TOWED EN
U1 0NAME(LAST,FIRST,M) mo yr
Unknown.0. Unknown Unknown 00-NONE 0 >.4:12 �/OUETOCRASH ❑
13-UNDER CARRIAGE 16 1 • 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 0 M
SYSTEM IN ENGAGED 15-OTHER 916.70P 3
9 9 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s iL 6 I,.4 COM VEH 0 Ea 1
~ 0 9 0 FIRST CONTACT 12 7_: __5 *II Yes.See Sidebar U1 0
Z UNK ' E
M TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 11/
UNK UNK ❑Y ❑N U2 I-
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same UNK 1 I-
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y El 99 0
m g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES O iiuv 0 iv ❑DV
!1 9 my yr78 Dodge Caravan(inc Grand)2014 oo-NONE 0.. Q!'-O DUE TO CRASH 0 (� 2 x
o 13-UNDER CARRIAGE 16 I f: 2 FIRE 0 ® U2 C
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3
❑Y NJ N El UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-iI�1:, 4 COM VEH D ® U1 W
FIRST CONTACT 12 7 .5 •If Yes.See Sidebar
F. ELGIN IL 60123 0 1 0 DW48678 IL 2014 RE 0
M
IL D 0 2C4RDGBG3ER428317 STATE FARM ❑Y ®N RDEF M
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
NAVARRO RIVERA.ADRIANA 2065001 SFP13 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE;ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((A.DDRESS)((TELEPHONE) (EMS) (HOSPITAL)
2 3 11 / M 2 3 0 1 0
m
/ / #OCCS D
/ / U1 1 D
/ / 2 0
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 5 04,01 /2025 04 14 ®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 ❑ 05 06
N 3 ❑ ❑CITATIONS ISSUED 0 PENDING + ! _ ❑PM• El Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5
—a, u ARREST NAME ! / El PM '
1 ® 11 5 0 CITATIONS ISSUED
SECTION CITATION NO. ROAD CLEARANCE TIME Ely PENDING • Utilit SLMT
S' El AM
t 2 El ARREST NAME 04 r 01 12025 04 14 ®PM El Unknown work zone type U1 1 O
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ ❑AM Workers present? ❑Y 10
1526 Walsh.Jacob 602 391-Jacobucci 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
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 -' I. INDICATE NORTH combination):or -I
N BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ i. e. (example:shuttle or charter bus):or 0
' i 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
aoe a.«w.&w
}----j;- --; I I - } } } transport) em to ees in the course of their em ng p y pbgeyment(example:employee
I aeuu..mew 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 passes rs,includi the driver,
for direct compensation(example:large van used for specific purpose):or O
' I
12 I Lany hazardous materialrequires_ 5. Is any vehicle used to transport (HAZMAT)thatm
placarding(example:placards will be displayed on the vehicle). XI
do D
CARRIER NAME Z
_ ADDRESS D
rn
.-Not To Seale i I CITY/STATE/ZIP
- MOTOR CARR.ID 0 Interstate 0 Intrastate
I r ❑ Not in Comm./Govt. 0 Not in Comm./Other
--- --4. - USDOT NO. ILCC NO. m
XI
Source of above 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 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
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
Silver 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