HomeMy WebLinkAbout2025-00020669 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100 V
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 ❑ON SCENE 3
VEHICLE/PROPERTY ®OVER$1,500 ®NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 2025I 2025-00020869 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 10 rl
® ❑ RELATED 0 Y ®N 04 03 2025 ®AM ❑YES ®NO U1 -<
RT20 WB Elgin01:14
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
EgP-0T/ N E SShales Pk COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW Cl)
® ® Cook HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
IYg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0 ICU 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0
0 2 /
yr 13-UNDER CARRIAGE al
10 !:. 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14--TOTAL(ALL) DISTRACTED 0 ]$I U2 m
M 5 OTHER
4 ❑Y ®SYSNE❑UNK VEH. ATCRASHIN n ENGAGED 9:UNKNOWN 9 t6.TOP 3 ,Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S_iL s 4 COM VEH 0 Ea 1 00
H F. PINGREE GROVE IL 60140-9155 A 1 0 FIRST CONTACT 12 Y ; _s *Irves.See Sidebar Ut
Z FS6700-MC IL 2024 ' E
TELEPHONE
IL D 0 MH3RH20Y4MK004369 NIA ❑Y ❑N U2 r
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 99 9 Same NIA 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Provena St.Joseph ❑Y ® N 9 2 XI
❑ DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 row
yr 12 _ 71
o 13-UNDER CARRIAGE 1U I c. 2 FIRE 0 0 U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 0 0 SPDR 0
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistracton Value U1 0 -
POINT OF s-.;, 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT Y�='+:-5 COM•I sYEH See •SideUar❑ 0
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F` REAR` C
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O
❑Y ❑N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
BAC
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
RESP❑YD❑N NDER U1 =
(UNIT) (SEATI (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0
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EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 36 1 04,03 /2025 01 17 ®❑AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1 �
v t 2 0 14 28 04,03 /2025 01 15 ❑PM 0 Construction *
R 3 0 ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME
z J ®AM ❑Maintenance U2
-a, ARREST NAME Benitez,Axel, D. 3-707 471000515 04/03/2025 01 24 ❑pM SLMT
o U 1 0 ig!CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM• ❑Utility
r 2 El ARREST NAME Benitez,Axel, D. 3-708 471000516 04/03 /2025 01 53 [El PM ElUnknown work zone type U1 45
n 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y
471-Evans, Lakysha 302 05 , 13/2025 09 00 ❑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.
. 0
r ----r••--, , L......,...... A CMV is defined as any motor vehicle used to transport passengers or property and: Z1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
;.__-_r-_--I ' combination):orINDICATE NORTH/ n BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
Lt - r rr (example:shuttle or charter bus):or 0
/ ro a.,.I T,_ / 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
I- <.__-A-.-.J _ / } I' l- I- transporting employees In the course of their employment(example:employee X
transporter-usually a van Type vehicle or passenger car):orCi_ .:. .}----I. _ _ ~` - 1 I- I- 4. Is used or designated to transport between 9 and 15 passengers,including the driver. w_ _ for direct compensation(example:large van used for specific purpose):or
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__ _ _ 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
/ `_ CARRIER NAME Z
// ADDRESS 'n
/ D
/ 0
CITY/STATE/ZIPg
- i. i. i. MOTOR CARR.ID 0 Interstate 0 Intrastate
i. C)
I I T I ❑ Not in Comm./Govt. Not in Comm./Other
; _Y_ _-1 USDOT NO. ILCC NO. m
XI
Source of above z
'
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_COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Black
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U_DUE ETOO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO:
DUE T VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE