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HomeMy WebLinkAbout2025-00021996 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 101101100 III 1100X(O100011IVV*11UUI111100 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY 3 34$14 u, 1 U2 1 1 1 U116 u2 u, 1 U2 u, 1 U2 4 6 u, 1 U2 *P 0119* 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 ❑5501-$1.500 ®ON SCENE 14 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash 0 AMENDED YR 202512025-00021996 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ® ❑ RELATED 0 Y ®N 04 08 2025 ®AM ❑YES ®NO U1 -< DAMISCH RD Elgin02:55 _ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m FT!MI N E S W W HIGHLAND G H LAN D AVECOUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW Cl) ❑ Kane HIT ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I ® &RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 8 0 0 9 / yr 13-UNDER CARRIAGE © O FIRE 0 ® < STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O O DISTRACTED 0 23 U2 m M 2 SY4 ❑Y ®SNE❑UNK VEH. AT CRASIN n H n is-OTHER 99-UNKNOWN 9 t6•TOP 3 `Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 16 �i 4 COM VEH 0 j$J 4 0 ~ RollingMeadows IL 60008 0 1 0 FIRST CONTACT 1 7 ;- -_5 *Irves.SeeSidebar U1 ZCZ25994 IL 2025 TELEPHONE IL 0 JTJBARBZ5F2041305 First Chicago Insurance C ❑Y ®N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same ILS 1020360-01 1 r o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ® N 2 ou ❑ DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 yr ,2 - C o 13-UNDER CARRIAGE 10 I 2 FIRE 0 ❑ 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 *Oistrac) n Value U1 9 - POINT OF s-.;, 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT Y 6 I,_ COMI s See SidebarEH 0 C CO F` REAR` 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 995 < RESP❑YD❑N NDER U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0 / / U2 r m Pj 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 43 2 04,08 ,2025 02 56 ®❑pM in a Work Zone? ®N DIRP co 1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 ;, 2 ❑ 37 08 1 s ! ! ❑PM ❑Construction * t Z3 0 xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 a u 1 0 ARREST NAME Cruz. Miguel,A. 11-709-A 752808 , , ❑PM I$!CITATIONS ISSUED ❑PENDING TIME ❑Utility SLMT o N SECTION CITATION NO. ROAD CLEARANCE AM 45 t 2 El ARREST NAME Cruz, Miguel,A. 6-303-A 752807 ! ! 0 pM ❑Unknown work zone type U1 n TIME OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE 2 3 ❑ ®AM Workers present? ❑Y 447-Collins, Dominique 901 331-Ziegler 04 !30/2025 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••--, , l r : A CMV is defined as any motor vehicle used to transport passengers or property and: > 1 N 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< ` ` '' -' f 0 r INDICATE NORTH combination):or p0 1 PTO 8 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C 11 _ (example:shuttle or charter bus):or 0 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 J ' transporter-usually a van type vehicle or passenger car):or w L L____a____� 4. Is used ordesi natedtotrans rtbetween9and15passengers,includingthedriver. C I / 1 } } } for direct compensation(example:large van used for speific purose):or N i W.?Highland?Ave -U __ f _ t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires / placarding(example:placards will be displayed on the vehicle). 71 XI i / D CARRIER NAME / Z // ' __ 1 ADDRESS 'n 1 1 CITY/STATE/ZIP n - i. i. i. 4. MOTOR CARR.ID 0 Interstate 0 Intrastate I I T I t ❑ Not in Comm./Govt. Not in Comm./Other Dark ?Rd ❑ 0 -Y- --1 USDOT NO. ILCC NO. m XI Source of above z . IDOT PERMIT NO. WIDELOAD-; ❑Yes 0 No = 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 ill TRAILER 2 ❑ 0 0 o u 1 COLOR U_COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Silver 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 ETOO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO:DUE T VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE