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HomeMy WebLinkAbout2025-00023094 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I01101100 VII I lI II II 110 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003 83, 32 u, 9 U21 2 4 1 U1 2 U2 1 u,99 u2 1 u,99 U2 1 1 10 u, 1 U2 3 .P0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00023094 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 71 WABASH ST Elgin 03:13 ® ❑ RELATED ®Y 0 N 04 12 2025 ❑AM ❑YES ®NO U1 -< _ _ g PRIVATE mo !day!yr ®PM FLOW CONDITION m FT!MI N E S W WALNUT AVE COUNTY PROPERTY El ® N DOORING ❑y #OF MOTOR 0 SLOW 1 0)0 Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n FOR DAMAGEDAREA(S) FPO Ni TOWED U1 Q Unknown. Unknown ! ! Unknown Unknown 00-NONE ©, 12 , DUE TOCRASH ❑ VI NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE IE 10 1- !�. 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m 9 9 SYSTEM IN 9 ENGAGED 9 ('-OTHER 9 16-TOP 3 ' _ ❑Y ElN CO LINK VEH. AT CRASH 9 UNKNOWN 6 4 `Distraction Value ALGN r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF ii 6 1i C.OM VEH 0 E! 1 0 I• 11 :FIRST CONTACT 7_ -__;_5_ *II Yes.See Sidebar U1 0 9 0 UNKNOWN RE 2 Z _ TELEPHONE UNKNOWN Unknown ❑Y ❑N U2 I' in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same Unknown 1 rn `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER en Refused 0 Y ® N 99 0 m g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 iiuv 0 KCv 0 DV '1 9$5 Honda CRV 2007 00-NONE 'o,� t2 (,-2 FIRE DUE ocRASH ® U2 2 C o 13-UNDER CARRIAGE ID c M 2 4SYSTEM IN 0 ENGAGED 0 ®-OTHER 911,6•TOP 3 9 9 X 0 Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN `0istraclIon Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF �'i 6 iY 4 COM VEH ❑ ® U1 CO C FIRST CONTACT 7 Q __,__5 •(ryes,See Sidebar ELGIN IL 60123 0 1 0 G729989 IL 2016 REAR 9 N IL A 7 J H LRE48547C061783 Progressive ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 = 99 9 Nhoybouahong. Lakhonesay 956405615 SAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP u1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) W 03 / :A / / UI 1 D / / 1 0 EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 11 4 04/12 /2025 03 13 ®pm in a Work Zone? ®N DIRP co 1 t PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 1 C) T v 1 2 0 2 28 1 / _ ❑PNI ❑Construction X Z 3 0 ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 ❑AM 0 Maintenance U2 a ARREST NAME / / ❑PM 1 11 4 ElUtility 0 CITATIONS ISSUED ❑PENDING SLMT o- N ® SECTION CITATION NO. ROAD CLEARANCE TIME t 2 ElARREST NAME 04/12 /2025 04 13 ®PM 0 Unknown work zone type U1 25 n T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 1548-Crandall. Matthew 701 ❑AM Workers present? ❑N 25 / / ❑PM ® 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 -' r INDICATE NORTH combination):or —I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C - } (example:shuttle or charter bus):or L A 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 transporter-usually a van type vehicle or passenger car):or CO 4. Is used or designated to transport between 9 and 15 passengers,including (I) -- -- , filF - } } } g po pafic p rs,includi the driver, O for direct compensation(example:large van used for specific purpose):or L L__ _a_ . A _ t } } i. 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires D placarding(example:placards will be displayed on the vehicle). m IN I CARRIER NAME z ADDRESS Not To Scale I D Ii. i. i. 4.i. 0 CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate 0 Intrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other ; _Y_ __ USDOT NO. ILCC NO. rn XI Source of above z . ❑ Yes 0 No 0 Unknown g D Did Carrier Safety Regulations MCS)violation contribute to the crash? ❑ Yes 0 No ❑ Unknown 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' 0 Yes 0 No 2 TRAILER VIN 1 m to LOCAL USE ONLY TRAILER VIN 2 m 0 TRAILER WIDTH(S) 0-96" 97-102" >102' m TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Blue.Light u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO: _ . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE