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HomeMy WebLinkAbout2025-00023328 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 I01101100 VI II 100 000 DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003/90228 u, 9 U21 3 4 1 U1 3 U2 1 U, 1 u2 1 U, 1 U2 1 1 12 u1 1 u2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY 0 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW ' Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash ❑AMENDED YR 2025I 2025-00023328 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 71 N MCLEAN BLVD El in 06:30 ® ❑ RELATED ❑Y ®N 04 13 2025 ❑AM ❑YES ®No u1 _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION ITT FT!MI N E S W WING ST COUNTY PROPERTY El ® N DOORING El #OF MOTOR 0 SLOW 15 u) ❑ 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 ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV ❑ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n 1 2 FOR DAMAGED AREA(S) FRO NAME(LAST,FIRST,M) Ames,Cornellius.A. mo / /1 9 8 9 r T TOWED U1 Q Nissan Murano 2011 00-NONE „_' ©0 ODE TO CRASH ® ❑ 13-UNDER CARRIAGE 1 FIREEI ID STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10• 0 DISTRACTED ® ElU2 4 M M 2 4 SY M IN ENGAGED 15- ❑Y ®N SEDUNK VEH. 0 AT CRASH 0 99-UUNKNOWN 9 16-TOPO `Distraction Value 9 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6_iL 6 i t 0 COM VEH 0 0 5 C) " �- SOUTH ELGIN I L 60177 0 1 0 FIRST CONTACT 1 7 :1 -® •irYes.See Sidebar U1 0 Z ER22842 IL ' E TELEPHONE IL 0 JN8AS5MV3BW687190 Kemper ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Elgin Fire Garcia,Griselda 12RA000005604 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 eu x DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEON. 0 EWES ❑ ivy 0 NOV ❑DV yr/1 9 6 8 Hyundai Tucson 2024 00-NONE ,�_' t2 -_, DUE TO CRASH p (� 2 0 13-UNDER CARRIAGE • o 1 2 FIRE ❑ ® U2 C c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 016•TOP 3 X ❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistracton Value 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 0'i 6. I.-4 COM VEH D ® U1 W ELGIN IL 60123 0 1 0 EQ72873 IL FIRST CONTACT 8 7 � _s •If Yes.See Sidebar 0 C IL 0 5NMJB3DE9RH369006 Geico ❑Y 123 N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X Same 4591632478 BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 < Refused RESPONDER U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI 1(EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) 1 7 02 / LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y N 1 ® 11 1 04,13 /2025 06 30 0 pm in a Work Zone? ®N DIRP co 1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 O 2 ❑ 28 15 / / ❑PM ❑Construction N 3 ❑ I!!I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM ❑Maintenance U2 a 1 ® 11 1 ARREST NAME Ames,Cornellius,A. 6-101 S1529-000364 / / ❑PM SLMT igi CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0• Utility o N AM 35 t 2 ❑ ARREST NAME Ames.Cornellius,A. 11-402-A S1529-000365 / / 0 pM ❑Unknown work zone type U1 2 2 3 ❑ - OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 35 1529-Audi red,Jonathan 601 05 /08,2025 09 00 0 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 -< ` ` --I -' r INDICATE NORTH combination):or —I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } ! t _ i. e. r t- (example:shuttle or charter bus):or 0 I i _ 3. Is designed to car 15 or fewer passengers and operated a contract carrier O N �' !°O w.d�sr. } } } transporting employees In the course of their employment(example:employee ^' _ I/ d� transporter-usually a van type vehicle or passenger car):or w i. -- -- 4"'• •"•••-•• ,.,`L �+�rr , � _r - } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver. w —__ a for direct compensation(example:large van used for specific purpose):or ............ 4 4 } } } t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m �--- _ placarding(example:placards will be displayed on the vehicle). XI /// `� e, ,10 CARRIER NAME a ADDRESS 0 1T. CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate 0 Intrastate 0 I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other --- --1 - USDOT NO. ILCC NO. m XI Source of above z . Was a driver/vehicle Examination Report Form completed? r HAZMAT ElYes 0 No ElUnknown Out of Service ❑Yes ❑No _< 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 to 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 Gray Gray u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT' 2 TOWED BY/TO. _Adieu/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY1T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE