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HomeMy WebLinkAbout2025-00022281 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100 IOU 110 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003784821 u, 1 U21 1 1 1 U1 8 U2 1 U, 1 1_12 1 U, 1 U2 1 1 12 u1 1 u2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW ' Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 10 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash 0 AMENDED YR 2025I 2OZ5-00022Z81 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ® ❑ RELATED ❑Y ®N 04 09 2025 IgiAM ❑YES ®NO U1 -< COOPER AVE Elgin 08:27 _ _ g PRIVATE mo !day!yr ❑PM FLOW CONDITION m FT!MI N E S W N LI BERTY ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Q83 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 3 0 0 7 ! yr 13-UNDERCARRIAGE i I! FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O 2 DISTRACTED 0 0 U2 3 <<T1 M 2 SYTM IN ENGAGE4 ❑Y ®SNE❑UNK VEH. O AT CRASHD O 99-UNKNOWN 016-TOP 3 *Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 0 i1 6 I'.4 COM VEH 0 El 1 C) Z Geneva I L 60134 0 1 FIRST CONTACT 9 O7 _; __5 *irYes.see Sidebar U1 0 DJ28444 IL 2025 REAR TELEPHONE IL D 0 UCF200096904 USAA Casualty ❑Y ®N U2 19 . m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same 0050199907103 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ® N 2 0 x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 ,uv 0 NCv 0 DV !2 0 0 5 Cadillac ATS 2014 00-NONE 11_"1 ©I O DUE TO CRASH 0 ❑ 2 x o 10 13-UNDER CARRIAGE I If. 2 FIRE ID El U2 C c F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOPO3 * X ❑Y NJ ❑UNK VEH. AT CRASH 99-UNKNOWN Oistracti n Value 0 s 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 I r COM VEH_, • n HANOVER PARK IL 60133 0 1 FB47301 IL 2026 aR IL D 0 1G6AH5RX6E0166219 Advantage Auto ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same 440900264748 BAc E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 < Refused RESPONDER U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME m Am Did crash occur 0 Y U2 Z N 1 ® 11 1 41 ,12 !25 08 27 PM in a Work Zone? ®N DIRP > co 1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 0 2 ❑ 20 28 1 , 0 PM ❑Construction * R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 o1 ® 11 1 ARREST NAME Cunningham.Jack.C. 11-708 465-442 / / ❑PM SLMT o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' 0 Utility 25 r 2 0 ARREST NAME AM 7 1 r ❑❑PM El Unknown work zone type U1 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 25 465-Dorado.Ariana 201 51 , 01 ,025 01 30 ®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-_--; combination):or INDICATE NORTH � BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver } I IL. ® _ } (example:shuttle or charter bus):or 3. Is desgned to car 15 or fewer passengers and operated a contract carrier O } A i I I } } } transporting employees In the courses of their employment(example:employee y a van type co L L.___a__ 4alsuosedordrter- estlnatedtotransehrtbetweeicle or n9andr15r) ssen rs,indudingthedrrver, } } } 9 Po Pa 9e (I) 1 �., for direct compensation(example:large van used for specific purpose):or O ' ( — j r'. L____a..... '- " — — — _ i i t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires R �i .i placarding(example:placards will be displayed on the vehicle). XI ii_'I CARRIER NAME Z t I t I t ADDRESS 0 T. Not To Scale I CITY/STATE/ZIP n MOTOR CARR.ID 0 Interstate El Intrastate 1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other i— -----"1 - USDOT NO. ILCC NO. rn XI Source of above Z . 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? ❑ 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 v 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 White Gray 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 VEHICLE CONFIG._CARGO BODY TYPE LOAD TYPE