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HomeMy WebLinkAbout2025-00022538 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I01101100 111111111111111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003784256 u, 1 u2 1 1 1 U1 2 u2 U, 1 u2 U, 1 u2 1 1 9 U1 14 U221 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW ' Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 7 VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and for Tow Due To Crash YR 2025I 2025-00022538 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 m120 S STATE ST El In10:56 ® ❑ RELATED 0 Y ®N 04 10 2025 ®AM El YES El NO U1 —< g PRIVATE mo /day/yr ❑PM FLOW CONDITION m _ COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR 0 SLOW 15 u) ❑ FT!MI N E S W Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I 0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Q83 DRIVER I] PARKED I]DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C) FOR DAMAGEDAREA(S) FROPtf TOWED U1 O Daniel. Mary.J. 0 4 / yr 13-UNDER CARRIAGE © IE 10,I• !�. 2 FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0U2 0 m F 2 4 ❑Y ® 15-OTHER SYSTEM ❑UNK VEH. 0 AT CRASH D 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s it s ii,4 COM VEH ❑ 0 1 0 m ~ ELGIN I L 60123 0 1 0 FIRST CONTACT 11 7_:, -__5 *II Yes.See Sidebar U1 Z AN54100 IL 2024 REAR TELEPHONE IL D Travelers Insurance ❑Y ign4 U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same 6171453102031 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER 73 D Refused ❑Y ❑ N 2 0 p DRIVER X. PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0!My 0 KCv 0 DV yr 13-UNDER CARRIAGE It.1 12 2 FIRE ❑ ® U2 C SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ ® SPDR C) 0 0 SYSTEM IN ENGAGED 15-OTHER 9.16-TOP 3 9 0 a ❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN *0istraction Value POINT OF 8 4 Ut N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR ��',_ COM VEH D ® CO FIRST CONTACT 1 Y A _, _5 •• •IfYes,See Sidebar H CJ47616 IL 2025 I:EaR 0 N M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 J H LRD78844C035601 State Farm ❑Y ®N RDEF 7) EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Both.Victor 3482185SFP13 BAC $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = {UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) OM (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME(!{ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0 O EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2Z N 1 ® 18 5 04,10 /2025 10 56 ®❑pM in a Work Zone? ®N DIRP co I I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 6 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 � 2 ❑ 03 15 N 3 ❑ CITATIONS ISSUED 0 PENDING + ! ❑PM El Construction SECTION CITATION NO. EMS ARRIVED TIME 6 ❑AM ❑Maintenance U2 —a, ARREST NAME / / El PM ' o N 1 ® 11 5 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT 05 ARRESTNAMEAM 7t 2 El AM PM ❑Unknown work zone type U1 1 / n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 410-DeLeon.Jessica 601 275-Engelke / / ❑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. A CMV is defined asmotor vehicle used to transportand: r ----,5-••--, ; any passengers or property Z 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< } i.-- -i-- --; } } } r -, , ; ; , 1, ( INDICATE NORTH combination):or —I p1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } ' i 1 , } (example:shuttle or charter bus):or X 3. Is L L.___A_. 1 <-- . -___� J transporting employened to es inhecourse 5 or fewer o their eers mplod yment example:employeener X } } } transporter-usually a van type vehicle or passenger car):or co < <.__-a-_-_, , l• < <--_-a-___� , , , , 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or 0 L L___-a____.: L L L ...._-..:_____� t i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example:placards will be displayed on the vehicle). XI --I CARRIER NAME Z ADDRESS 0 co CITY/STATE/ZIP MOTOR CARR.ID 0 Interstate ❑ Intrastate 0 ❑ Not in Comm./Govt. ❑ Not in Comm./Other O USDOT NO. ILCC NO. m XI Source of above 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 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 Blue 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