HomeMy WebLinkAbout2025-00021609 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I01101100 0
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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 51,500 El NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and f or Tow Due To Crash YR 2025I 2O25-00021609 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED PRIVATE ❑Y ®N 04 06 2025 DAM ❑YES ®NO U1 -<
LARKIN AVE Elgin mo /day/yr 1220 ®PM FLOW CONDITION m
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70(��C.7 COUNTY PROPERTY 0 Y ® N DOORING El #OF MOTOR 0 SLOW Cl)
® /MI NOS W Jane Dr WITH VEHICLES INVLD 0 STOPPED U2 --I
IDAT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑V ® N PEDALCYCLIST®N ® FREE FLOW # LNS 0
ti DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
0 8 J
yr 13-UNDER CARRIAGE I!. 2 FIRE 0 ® C
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 0 U2 m
F 2 4 SY❑Y ®SNE❑UNK VEH. 0 ATCRASHD15-OTHER
0 99-UNKNOWN 016•71DP 3 `Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s il_6 I, 4 COM VEH ElE! 1 O
FIRST CONTACT 3 7 'mR-- *II Yes.See Sidebar U1
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Z Dekalb IL 60115 0 1 0 TNKRBLL IL 2025 ' E
TELEPHONE
IL D 0 2HKRS4H41SH421814 Geico ❑Y ®N U2 r 1 R
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 6086-02-59-51 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 ou
❑ DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES 0 NW 0 Ncv 0 DV
yr 12 _ C1
.0 13-UNDER CARRIAGE 10 I 2 FIRE ❑ ❑ U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 ❑ ❑ 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 TA—d:=6 COM•I sVEH See •Sidebar❑ 0
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M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O
❑Y ❑N RDEF
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❑YD❑N NDER U1 =
(UNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 43 1 City of Elgin Damaged crosswalk sign 04/06 ,2025 12 20 0 AM 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
v t 2 ❑ 150 DEXTER CT ELGIN IL 60120 06 99 ! ! ❑AM El Construction *
R ) ❑ El CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME
3 ❑AM ❑Maintenance U2
-a, ARREST NAME Plazewski.Theresa. M. 11-601 W1531000023 ! ! ❑PM SLMT
o N 1 ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility
30
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 ❑ - ID Am Workers present? ❑
1531 SchE mbach.Jack 602 ! / ❑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
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1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
} 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 CO
< <.__-a-_-_, , < <--_-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 ,.___-.�____� 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
i.
ADDRESS 0
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
. m
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z
own tank)? 0 Yes 0 No 0 Unknown
T.
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
0
TRAILER WIDTH(S) 0-96" 97-102" >102' T
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