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HomeMy WebLinkAbout2025-00021330 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I01101100 HIM 1111 111E1 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003785478 u, 1 U2 3 4 2 U, 4 U2 U, 1 1_12 U, 1 U2 5 6 U1 1 U2 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT El 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 El NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash 0 AMENDED YR 202512025-00021330 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 r1 ® ❑ RELATED PRIVATE ❑Y ®N 04 05 2025 ®AM El YES IX]NO U1 —< W ROUTE 20 Elgin mo /day/yr 0120 ❑PM FLOW CONDITION m COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW Cl) ONO/MI N E O W Illinois Ave WITH VEHICLES INVLD 0 STOPPED U2 --I ID AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑V ® N PEDALCYCLIST®N ® FREE FLOW # LNS 0 18: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 03 T TOWED U1 Q Ochoa.Tanya Hyundai Kona 2025 00-NONE • 12 , DUE TO CRASH ® ❑ NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE ©1 2 FIRE ❑ alC STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 0 U2 m F 2 5 ❑Y ®SNEM❑ n is-OTHER UNK VEH. AT CRASHIN n ENGAGED 99-UNKNOWN 0t5.7DP 3 *Distraction Value ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF ,ii 6 I'.4 COM VEH 0 )g! 4 C) ELGIN IL 60120 0 1 0 FIRST CONTACT 11 O7 _; __5 *II Yes.See Sidebar U1 0 Z EL88714 IL 2026 REAR TELEPHONE IL 0 5NMJCCDE1 SH476263 Geico ❑Y ®N U2 ni 5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m co 99 Same 6169970164 2 r o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ® N 2 0 ❑ DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NuV 0 i v 0 DV yr 12 _ C1 o 13-UNDER CARRIAGE 10.i t, 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 ❑ ❑ SPDR n ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value U1 3 - POINT OF s-.;, 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT Y.='+:-5 C•IO e1sVEH See •Sidebar❑ 0 C CO F` ----, co 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) (SEATI (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) n / / U2 r m 01 71 / 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 43 2 04,05 l2025 01 20 ®❑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 2 ❑ 20 99 ! ! ❑PM. ❑Construction Z3 ❑ ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 —a, SLMT ARREST NAME ! ! _ ❑PM ' o u 1 ❑ ❑CITATIONS ISSUED ❑PENDING • Utility o N SECTION CITATION NO. ROAD CLEARANCE TIME ❑ AM U,_ 55 t 2 ❑ ARREST NAME 04!05 /2025 01 30 [M PM ElUnknown work zone type cf T n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑Y 2 3 ❑ - ❑AM Workers present? 1521-Vega.Wendy 401 ! ! ❑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 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< ` ` -' -' 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 , X I------..-- r-► 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 w L }-----}----I. I - - I. } } 1. 4. Is used or designated to transport between 9 and 15 passengers,including the driver. N •for direct compensation(example:large van used for specific purpose):or 0 L i t i ._ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m placarding(example:placards will be displayed on the vehicle). XI —1 CARRIER NAME Z 1 ADDRESS CITY/STATE/ZIP 00 MOTOR CARR.ID 0 Interstate ❑ Intrastate I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other ‘I. - --1 - USDOT NO. ILCC NO. m XI Source of above z . GVWR/GCWR m 0 <10,000 0 10,000-26,000 0 >26,000 z —I Were HAZMAT placards on vehicle? 0 Yes 0 No = If Yes,Name on placard O 4 digit UN NO. 1 digit Hazard class No. Xl Xl Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z own tank)? 0 Yes 0 No 0 Unknown 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? A ❑ Yes II El Unknown C 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 cn 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. _Adieu/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U_DUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/T6 DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE