Loading...
HomeMy WebLinkAbout2025-00019607 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 01101100 IVI I I DillIIII0 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003{92.217- u, 1 U21 3 4 1 U116 U2 1 U, 1 u2 1 U, 1 U2 1 1 11 U1 1 U2 1 *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 ❑$501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ❑OVER 51,500 ❑NOT ON SCENE(DESK REPORT) ❑AMENDED ❑ B Injury and/or Tow Due To Crash YR 2025512025-00019607 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ® ❑ RELATED PRIVATE ❑Y ®N 03 28 2025 DAM ❑YES ®NO U1 S RANDALL RD Elgin mo /day/yr 03:08 ®PM FLOW CONDITION m _ 10(� • COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 cn ® 1C.'J!MI O E S W South St WITH VEHICLES INVLD 0 STOPPED U2 --I El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑Y ® N PEDALCYCLIST®N ® FREE FLOW # LNS 0 (8:DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 C) FOR DAMAGEDAREA(S) FRONT TOWED EN U1 0Clark.Autumn. 1 1 / yr 13-UNDER CARRIAGE ©,I :: FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® 0 U2 4 rn M 2 4 ❑Y ®N SYSTEM ❑UNK VEH. 0 AT CRASHD 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value 1 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�a 4 COM VEH 0 1� 1 O F. FIRST CONTACT 12 7, ;—_,_-5 *II Yes.See Sidebar U1 Z SOUTH ELGIN IL 60177 0 1 0 DS74436 IL 2025 Ia TELEPHONE IL D 3VWCC21 C1 XM446106 Progressive ❑v ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m CLARK. NATALIE. R. 964648892 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 XI p; DRIVER ❑ PARKED ❑DRIVERLESS 0 FED ❑PEDAL 0 EWES ❑iiuv 0 i v 0 DV � 1 9 5 9 Porsche Macan 2023 00-NONE 1(FR"j 12..-_, DUE TO CRASH ❑ 2 x 0 13-UNDER CARRIAGE 10'( 2 FIRE ❑ El U2 C c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value 0 POINT OF s i 4 COM VEH ❑ ® U1 W N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6 FIRST CONTACT 6 O7 ,�=QIO•IfYes See Sidebar C Z ST CHARLES IL 60175 0 1 0 DQ13125 ILaR 0 fn D IL D WP1AG2A54PLB36872 State Farm ❑y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same 1264539-sfp-13 BAG E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER U1 = (UNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJI (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 N 1 ® 11 1 31 ,81 ,025 03 08 ®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 � 0 2 ❑ 41 28 , , ❑PM ❑Construction * R 3 ❑ $I CITATIONS ISSUED El PENDING PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 oER 11 1 ARREST NAME Clark.Autumn.j. 11-601 1517-000423 , r ❑PM SLMT o N 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility 50 t 2 ARREST NAME AM 7 1 r ❑❑PM El Unknown work zone type U1 El 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑y 50 1517-Le Cates. Brittany 801 391-Jacobucci 41 , 51 ,025 09 00 ❑PM123 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. A CMV is defined as for vehicle used to transportand: r ----,5-••--, ; any motor passengers or property Z 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< - i.----i-- --; } } } r - , ; ; , ; ( INDICATE NORTH combination):or —I p1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } ' i 1 , } (example:shuttle or charter bus):or X 3. Is . L.__-A_. 1 i. ..._... . J transporting edmployeeslIn5 hecourseeo theire rsmployment example:employeener X } } } transporter-usually a van type vehicle or passenger car):or 1:0 < <.__-a-_-_- , < <--_-a-___� 1 , , , 4. Is used ordesi nated to trans rt between 9 and 15 passengers,including C} } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or 0 L L___-a____.: L L L ...._-.�_ ; l. i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example:placards will be displayed on the vehicle). XI CARRIER NAME Z ADDRESS 0 , n CITY/STATE/ZIP MOTOR CARR.ID 0 Interstate ❑ Intrastate 0 ❑ Not in Comm./Govt. ❑ Not in Comm./Other 0 USDOT NO. ILCC NO. m XI Source of above z . Form Number m Xl IDOT PERMIT NO. WIDELOAD-; ❑Yes 0 No 2 TRAILER VIN 1 m co LOCAL USE ONLY TRAILER VIN 2 m a 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 Red Gray u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 2 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