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HomeMy WebLinkAbout2025-00022331 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003 2;6227' u, 9 U21 1 1 8 U1 2 U299 U199 U299 U,99 U2 1 1 15 U1 1 U223 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00022331 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m530 VILLA ST El11:59 ® ❑ RELATED ❑Y ®N 04 09 2025 ®AM ❑YES ®NO U1 _ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n ❑ FT!MI N E S W Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I O AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n ! ! f4T FOR DAMAGEDAREA(S) FRO TOWED EN U1 0Unknown.0. Unknown Unknown 00-NONE ©, >2 0 OUETOCRASH ❑ NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 10.I 2 FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0U2 2 m SYSTEM IN ENGAGED 15-OTHER 916.70P 3 M 9 9 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN = s 4'a- CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF ,Ii_6 1i._ 1 I- 0 9 FIRST CONTACT 7_: COM VEH ❑ ZgJ 1 _5 *lIVes.See Sidebar Ut 0 REAR 2 Z ' E TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 11/ Unknown ❑Y ❑N U2 I- 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same Unknown 1 rn `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ❑ N 99 0 g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑NMV 0 NCv 0 DV !2 0 0 4 Toyota Camry 2018 00-NONE It-' 12..`1 DUE TO CRASH ❑ C 2 73 o 13-UNDERCARRIAGE 10;1 2 FIRE ❑ ® U2 C li F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN O *Distraction value 9 g N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 iII 6 , 4 COM VEH ❑ ® U1 W F,,, FIRST CONTACT 5 •--,= 05 •If Yes.See Sidebar C ELGIN IL 60120 0 1 0 FB79043 IL FIRST Si)0 IL 0 4T1 B11 H K7J U557172 Progressive ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X 99 9 Same 994474973 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPOND 0 N U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 11 9 04,09 l2025 11 59 ®❑pM in a Work Zone? ®N DIRP co 1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 5 n T v 2 0 2 30 ) / 0 PM ❑Construction * Z 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM 0 Maintenance U2 -a, ARREST NAME / / ❑PM ' 1 ® 11 1 ❑CITATIONS ISSUED ❑PENDING Utilit SLMT o N SECTION CITATION NO. ROAD CLEARANCE TIME ❑ y AM 30 t 2 0 ARREST NAME 04 r 09 /2025 11 59 MPM ElUnknown work zone type U1 n T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ ❑AM Workers present? ❑Y 30 1543-Sturgeon. Kyle 300 275-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 t ADDITIONAL UNITS FORMS. r ----r••--, , I ; A CMV is defined as any motor vehicle used to transport passengers or property and: z i- i•____r____; II combingor more than pound (example:truck ortruckrtrarler -< 1. Has a weight rating10 000 5 .ti INDICATE NORTH tan) -I p3 `- --_+-- - BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C _ (example:shuttle or charter bus):or 0 J T, •.. a 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O I- }-----I---- Vn wemromnenaro7v�nvs�Ji - • l' } } transportingemployees in the course of their employment(example:employee X transporter-usually a van type vehicle or passenger car): r � L }----------; i - } } 1 4. Is used or designated to transport between 9 and 15passengers,including the driver. C i I for direct compensation(example:large van used fors specific purose):or O ' • lIl I • L i i 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires . . placarding(example:placards will be displayed on the vehicle). m wovvwaa D 111 XI I - CARRIER NAME Z q ADDRESS 'O III I d Not To Scale f D CITY/STATE/ZIP 0 MOTOR CARR.ID 0 Interstate 0 Intrastate l ❑ Not in Comm./Govt. 0Not in Comm./Other 0 i-----Y----4. M`'t - USDOT NO. ILCC NO. m XI Source of above z . If Yes,Name on placard O 4 digit UN NO. 1 digit Hazard class No. XI XI 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 VIM 1 m co LOCAL USE ONLY TRAILER VIN 2 m 0 TRAILER WIDTH(S) 0-96" 97-102" >102' -n TRAILER 1 ❑ ❑ 0 Z 1-1 TRAILER 2 ❑ 0 0 o u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Blue u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT g TOWED BY/TO: _ . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO. DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE