HomeMy WebLinkAbout2025-00021481 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 0111110 111111 01101100111111111� ���� U��
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑5501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 202512025-00021481 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m
CONGDON AVE El In08:01
® ❑ RELATED ®Y 0 N 04 05 2025 12,.. ❑YES ®NO U1 —<
g PRIVATE mo !day/yr ®PM FLOW CONDITION ITl
010 !MI N E SEast Chippewa Dr COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 cn
® ® ® pp Cook 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
183 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 n
/ ! FOR DAMAGEDAREA(S) FROr'tf TOWED EziU1 0Unknown Unknown Unknown 00-NONE ,, 12 OUETOCRASH ❑
NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE ! FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 'O
M 9 IE
9 SYSTEM IN 9 ENGAGED 9 15-OTHER 976.70P�3 DISTRACTED 0 0 U2 3
❑Y ElN ®UNK VEH. AT CRASH 99-UNKNOWN 6 4 Distraction Value 9 ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF l 6 �I COM VEH 0 0 1 n
I— FIRST CONTACT 3 7 _ --_;__5 *IIYes.See Sidebar U1 0
0 9 0 UNKNOWN Unknown T'
2 Z
M TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 11/
UNKNOWN UNKNOWN ®Y ❑N U2 13 . m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same UNKNOWN 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
'',3D Y°®N
m
N DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑Nuy ❑i v ❑Dv
!2 0 0 4 Kia Motors Coilptima 2013 00-NONE „ _.OI'0 DUE TO CRASH rg ❑ 2 x
o -y Yr 13-UNDER CARRIAGE i,, FIRE 0 ® U2
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 016-TOP 3
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN )I *Oistractlon Value 9 g
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR PFIRST CONTACT 1 NT OF O 0 � 5 C•IOMs gee SidebarH ® U1 to
ZGenoa IL 60135 0 1 0 EL41521 IL REAR 0 Si)
Z
IL 0 SXXGN4A71 DG097166 Geico ❑Y ®N RDEF M
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 X
Carreto.Giovanni.T. 6006937376 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (D081 (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE! (EMS) (HOSPITAL)
W 03 /
DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 Panisse Negron. Barbara. M. Stone barrier base 04,05 /2025 08 01 ®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 C)
Fic 2 0 926 CONGDON AVE ELGIN IL 60120 04 99 / / PM
❑ • 0 Construction *
Z 3 ❑ 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM 0 Maintenance U2
—a, ARREST NAME / / ❑PM '
o u1 0 11 1 0 CITATIONS ISSUED ❑PENDING UtilitySLMT
N SECTION CITATION NO. ROAD CLEARANCE TIME • ❑AM
S' t 2 El34 2 ARREST NAME 04 r 05 l2025 08 01 ®pM ElUnknown work zone type U1 30
n 7 OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ ❑AM Workers present? 0 Y 30
1500-Chew. Marie 201 391-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
more than pound (example:truck or truck trailer -<
1. Has a weight rating10,000 5
i- }----i-----; MB da zAve EDI - combination):orzcare INDICATE NORTH p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_Not To Scale J - i. e. (example:shuttle or charter bus):or 0
L A I 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
} } } transporting employees In the course of their employment(example:employee X
coriorka Aw ) transporter-usually a van type vehicle or passenger car):or w
4. Is used or designated to transport between 9 and 15 passengers,including ((I)
-- 'L } } g po the driver,
for direct compensation(example:large van used for specific purpose):or O
1
L____a____. -- t 5 Is an anyvehicle(examplused lacard transport splaedon veh le). T)that requires
l A i pWcardmg(example:placards will be isplayed on the vehicle). m
l �l
0
unit C- __
CARRIER NAME Z
_ ADDRESS 0
n
, CITY/STATE/ZIP g
_ MOTOR CARR.ID 0 Interstate 1:: Intrastate
l I . V
l ❑ Not in Comm./Govt. 0 Not in Comm./Other
' 'Y "' USDOT NO. ILCC NO. m
XI
Source of above z
. MCS 0 Yes 0 No 0 Unknown Out of Service 0 Yes ❑No 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 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Red Bronze
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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® Other/Unknown VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE