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HomeMy WebLinkAbout2025-00023161 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 4 Sheets 01111101111 I01101100 VII I III 011100 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X(03 83 16 u, 1 U21 2 4 1 u, 2 U2 1 u, 1 1_12 1 u, 1 U2 1 5 15 u1 1 U2 1 *P 0119 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 ❑$501-51.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash 0 AMENDED YR 2025I 2025-00023161 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 '1 N MCLEAN BLVD Elgin 10:02 ® ❑ RELATED 181 V 0 N 04 12 2025 12,— ❑YES ®NO U1 -< g PRIVATE mo /day/yr ®PM FLOW CONDITION M FT N E S W LAWRENCEAVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 15 u) ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N 51 FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0 Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 00 0 0 9 / yr 13-UNDER CARRIAGE ©, p- FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O O DISTRACTED 0 ]$� U2 00 I<T1 F 2 5 15-OTHER ❑Y ®N SYSTEM ❑UNK VEH. O AT CRASH O O 99-UNKNOWN 9 16•TOP 3 `Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF T_iL 6 I,.4 COM VEH 0 j$J 1 O ~ HuntleyI L 60142 0 1 0 FIRST CONTACT 12 7_: __5 *If Yes.See Sidebar U1 Z 6283624 IL 2026 TELEPHONE IL 2C4RC1 EG1 LR126758 American National ❑v ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Elgin Fire 99 9 Same 12A6514H5 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ® N 1 c Eg DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑iiuv 0 KCv ❑DV Yr /1 9 9 7 Ford Explorer 2024 00-NONE „ " Oj-_, DUE TO CRASH ❑ 6 13-UNDER CARRIAGE I, FIRE 0 ® U2 C c F 2 5 SYSTEM IN 0 ENGAGED 0 15-OTHER 016-TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF O I• ••,.4 COM VEH 0 ® U1 CO H FIRST CONTACT 11 7 _, _5 *If Yes,See Sidebar C ELGINz IL 60120 B 1 0 MP22114 IL I 0 Si) M IL 1 FM5K8ACXPGA19840 CHARTER OAK FIRE ❑y ®N RDEF71 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 = Elgin Fire 99 9 City of Elgin 8109160P901 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP u1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) 1 4 10 / LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ID Z N 1 ® 11 4 41 /21 /025 10 02 ®AM 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 7 n T o" 2 ❑ 2 28 / / ❑PM- ❑Construction N 3 ❑ ill CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM ❑Maintenance U2 o1 ® 11 4 ARREST NAME Bromann,Stacy.J. 11-901-A 1506-383 / / El PM SLMT o H • 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility t 2 ❑ ARREST NAME AM T / / pM El Unknown work zone type 30 U1 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? D Y 30 1506-Nunez. Maria 602 51 , 31 /025 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. r ----r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z } }----i-----; UNIT 0 - combination): r gmore thanpound (example:truckortruck/trailer 1. Hasaweight ratio 10,000 5 -I INDICATE NORTH o p0 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } ; Not To Scale ,. ,. (example:shuttle or charter bus):or L I- --I-- £ UNIT zI } } } transporting employened to es the course or fewer of their eers mplod yment example:employeerier ZOI transporter-usually a van type vehicle or passenger car):or CO LAWRIENCOAVE i- -----------. rL P- - • } } } 4. Is used or designated to transport between 9 and 15 passengers,including the driver. C 7 # # ` for direct compensation(example:large van used for specific purpose):or O L L____a____. t i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires ill — — — — — — placarding(example:placards will be displayed on the vehicle). ;p —1 CARRIER NAME Z r r -1- -: r —� I ADDRESS 0CITY/STATE/ZIPC) MOTOR CARR.ID ❑ Interstate El Intrastate I r ❑ Not in Comm./Govt. 0 Not in Comm./Other ; _Y_ __1 USDOT NO. ILCC NO. m XI Source of above z . 0 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? ❑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 Gray Black u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO. Arties/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE