HomeMy WebLinkAbout2025-00022743 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
01101100 00 11101 1110
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003784234
u, 1 U21 1 1 1 u1 2 U2 1 U1 1 U2 1 U1 99 U2 99 1 11 U1 1 U2 1 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY [8]OVER$1,500 ❑NOT ON SCENE(DESK REPORT) El Injury and f or Tow Due To Crash
El AMENDED
YR 202512025-00022743 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 m381 S LIBERTY ST El In07:51
® ❑ RELATED ❑Y ®N 04 11 2025 ®AM El YES El NO U1 -<
g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
_
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 co
❑ FT/MI NESW Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ® STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS O
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
1 FOR DAMAGEDAREA(S) FRO r TOWED U1 Q
m 0 /
13-UNDER CARRIAGE 1a , 2 FIRE 0 IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 2 m
F 2 SY4 ❑Y ❑SNE®UNK VEH. 9 AT CRAS IN H 9 15-OTHER
99-UNKNOWN 9 16•TOP 3 `Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 iL 6 �i, COM VEH ❑ j$J 1 0
~ ELGIN I N I L 60120 0 1 FIRST CONTACT 1 7_; __5 *II Yes.See Sidebar Ut
Z EY38938 IL 2026 REAR
TELEPHONE
IL D WA1 LGAFE5DD002305 Geico ❑Y ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
1 99 9 Same 6176-07-39-49 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER 73
73
Refused ❑Y ❑ N 2 0
m x DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑Nuv 0 i v ❑DV
yf 5 Jeep(after 196g)ind Cherokee 2015 00-NONE +i_-I 12..-_1 DUE TO CRASH rg ❑ 2 73
o 13-UNDERCARRIAGE 10;1 2 FIRE ❑ ® U2 C
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F 2 4 SYSTEM IN g ENGAGED g 15-OTHER 9 16•TOP 3
❑Y ❑N ®UNK VEH. AT CRASH 99-UNKNOWN *OiNractIon Value g g
POINT OF 8 iI 4 COM VEH ❑ ® Ut W
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR - 6 �'_
FIRST CONTACT 6 Y__{_O ._5 •If Yes.See Sidebar
— Elgin IL 60107 0 1 0 V897721 IL 2025 REAR 0 C
IL D 1 C4RJFBG8FC104194 American Family ❑Y ®N RDEF 73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 41064-52539-91 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND O N 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 Did crash occur ❑Y U2 Z
u 1 ® 11 1 04,11 l2025 05 51 ®AM 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
Si 2 ❑ 28 03 { ) ❑PM ❑Construction *
1
Z3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 1
o1 ® 11 1 ARREST NAME Neto.Amanda.A. 11-601-Ax 430000471 / ! ❑PM SLMT
o N
0 CITATIONS ISSUED ❑
PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • Utility
30
r 2 ARREST NAME AM
7 1 r ❑❑PM 0 Unknown work zone type U1
% El
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 30
430-Nemt�ev.Sergey 401 05 , 13,2025 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
I ADDITIONAL UNITS FORMS.
r ----r••--, , I A CMV is defined as any motor vehicle used to transport passengers or property and: Z
�. ratingmore than pounds(example:truck or truck trailer -<
1. Has a weight 10,000
i- }____r____; } combination):or
INDICATE NORTH p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- } r r r (example:shuttle or charter bus):or 0
1: 3. Is des ned to car 15 or fewer g ry passengers and operated by a contract career 0
0 I ... I. } } transporting employees in the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or w
4. Is used or designated to transport between 9 and 15 passengers,including rCjt
} } g po passen rs,includi the driver,
for direct compensation(example:large van used for specific purpose):or
Not To Scale I It i. < i. L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
I I I placarding(example:placards will be displayed on the vehicle). ;p
CARRIER NAME Z
ADDRESS 0
w
C)
CITY/STATE/ZIP g
_ MOTOR CARR.ID ❑ Interstate ❑ Intrastate
r I I<,,"-"'r!."1 ❑ Not in Comm./GaA. Not in Comm./Other
1 i [..-- USDOT NO. ILCC NO. m
Source of above z
. xi
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z
own tank)? 0 Yes 0 No 0 Unknown
T.
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
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
Black White
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
Arties/Owners Residence . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE