HomeMy WebLinkAbout2025-00022914 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S 1215501-51.500 ®ON SCENE 1
VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
El AMENDED
YR 202512025-00022914 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
441 G EORG E ST Elgin06:29
® ❑ RELATED ❑Y ®N 04 11 2025 12,— ❑YES ®NO U1 -<
_ PRIVATE mo /day/yr ®PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ FT,MI NESW 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 O PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0 Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
0 3 /
yr 13-UNDER CARRIAGE ) 2 , 2 FIRE ❑ ® <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 m
M 2 SY4 ❑Y ®SNE❑UNK VEH. O AT CRAS IN H O is-OTHER
99-UNKNOWN 9 76•TOP 3 `Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ ;iI S 4 COM VEH ❑ Ea 1 0
~ ELGIN I L 60120 0 1 0 FIRST CONTACT 12 7 ;1 _5 *II Yes.See Sidebar Ut
Z FD11632 IL 2025 E
TELEPHONE
IL D 0 1 N4AL21 El9N557720 State farm ❑Y Il N U2 m
5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 1326491-SFP-13 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 2 ou
0 DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0
yr ,t 12 -1 ❑ ® 1 73
C
o 13-UNDER CARRIAGE ta;l 2 FIRE ❑ El U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR n
SYSTEM IN 0 ENGAGED 0 15-OTHER 9 +6.TOP 3 9 9
a ❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN *Oistractlon Value U1
POINT OF S {I 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR S �L_ COM VEH ❑ ® CO
FIRST CONTACT 6 Y__{_O ._5 •IfYes.See Sidebar
H ZU57853 IL 2025 REAR 9 fp
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
KL1TD62655B343203 All State ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Call.Suzanne 922643260 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
{UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),{ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
0 O
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2Z
u 1 ® 18 1 04,11 ,2025 06 29 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 .,
5 2 ❑ 28 50 , ) ❑PM ❑Construction *
Z 3 0 Igi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
a 1 ® 11 1 ARREST NAME Montoya. Eduardo 11-305-A 752818 , r El PM SLMT
l$!CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM• 0 Utility
r 2 0 ARREST NAME Montoya. Eduardo 11-402-A 752817 04,11 ,2025 08 26 ®PM El Unknown work zone type U1 25
2 2 3 ❑ OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 25
1548-Crandall. Matthew 401 04 , 12,2025 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••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
r combination):. Hasr more than pound (example:truck or truck trailer
1. a weight rating10 000 5
INDICATE NORTH o A
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
I - } (example:shuttle or charter bus):or
N T
3. Is designed to carry15 or fewer passengers and operated a contract carrier 0
- -----------i
S.- transporting employee In the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or CO
L L.___a____.I ' 4. Is used ordesi natedtotrans rtbetween9and15passengers,includingthedriver,
�; I. } } for direct compensation(examp large van used for speific purose):or 0
L L----a----. MD - t i i i ._ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
D
— placarding(example:placards will be displayed on the vehicle). XI
t,I- I- -:- ''. 2:.Con oe�� CARRIER NAME Z
Z
ADDRESS 0
w
Not To CITY/STATE/ZIP 0
Scale 5
--+ i. i. i. i. MOTOR CARR.ID 0 Interstate 0 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
. —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
71
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's Z
own tank)? 0 Yes 0 No 0 Unknown D
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes 0 No 0 Unknown g
Did Carrier Safety Regulations MCS)violation contribute to the crash?❑ Yes IQNo El Unknown Unknown 0
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
O
TRAILER WIDTH(S) 0-96" 97-102" >102' T
TRAILER 1 ❑ ❑ 0 z
ri
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' 1 TOWED BY/TO.
_Adieu/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE