HomeMy WebLinkAbout2025-00024722 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003790181
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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 El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ❑OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00024722 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 mDUNDEE AVE Elgin03:38
® ❑ RELATED 0 Y ®N 04 19 2025 12,-- ❑YES ®NO U1 -<
_ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION MFTlMI N E S W RIVER BLUFF RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (/)
❑ 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
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
f4T TOWED U1 O
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NAME(LAST,FIRST.M) Graves.Clarence mo Kia Motors Coi Iluride 2021 00-NONE
13-UNDER CARRIAGE ,,;•
12 -0 DUE TO CRASH 0
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) !� FIRE ❑
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STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 1U O DISTRACTED 0 0 U2 2 rrl
M 2 4 SY❑Y ®SNE❑UNK VEH. 0 ATCRASHD15-OTHER
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 iI 6 �i 4 COM VEH ❑ Ea 1 0
~ ELGIN I L 60123 0 1 0 FIRST CONTACT 3 7_; -_5 *II Yes.See Sidebar U1
Z CS76961 IL 2025 REAR
TELEPHONE
IL 0 5XYP6DHC4MG179775 Statefarm ❑Y ®N U2 I'
Ill13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 0152960-SFP-13 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 c
p; DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 rouv
/2 0 0 2 Nissan Sentra 2020' 00-NONE „ " 12 " , DUE TO CRASH ❑ (� 2
13-UNDER CARRIAGE FIRE 0 ® U2
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER O9 16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istraellon Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 5 ) 6 i',.4 COM VEH ❑ ® Ut CO
F,,, FIRST CONTACT 9 7 _, _5 •IfYes.See Sidebar C
ELGIN IL 60120 0 1 0 CB72822 IL 2025 Si)0
M
IL D 0 3N1AB8DV5LY231430 Geico ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 8 x
99 9 Arroyo.Christian 4565932037 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
u1 =
(UNIT) (SEAT) (DOBI (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME))(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
1 4 05 /
1 ® 11 1 04,19 /2025 03 38 ®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 ,,
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2 0 20 12 / / ❑PM ❑Construction *
1
Z 3 0 lyg CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
o1El 11 1 ARREST NAME Graves.Clarence 11-709-A 1553000034 , / El PM SLMT
o N 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility
AM
t 2 ElARREST NAME , / ❑❑pM 0 Unknown work zone type U1 30
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1553-Jentsch.Clarissa no05 ,27,2025 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•---, , I A CMV is defined as any motor vehicle used to transport passengers or property and: Z
�____r____; I _ 1. Hasor than pounds(example:truck ortrucktrailer -<1. Has a weight rating more10 000
INDICATE NORTH tan) p3
Not To Scale J BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
_ - _ (example:shuttle or charter bus):or
_ f f T,
1 '• rw ® 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 1 O
L----A----' r
, - } } } transporting employees in the course of their employmentge (example:employee �
t t transporter-usually a van type vehicle or passenger car):or w
L L.___a____� 1 I 1 4. Is used ordesi natedtotrans transport passengers,including y- } } } g po passes rs,includi the driver,
for direct compensation(example:large van used for specific purpose):or O
i. i 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
13
a I placarding(example:placards will be displayed on the vehicle).
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CARRIER NAME —I
- __ ADDRESS 0
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CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate ❑ Intrastate
1 I r 1 .1- I , t I t ❑ Not in Comm./Govt. 0 Not in Comm./Other 00
i-""Y""1 USDOT NO. ILCC NO. C
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XI
Source of above z
. 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' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Gray Blue
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 0 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