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HomeMy WebLinkAbout2025-00026130 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 0110110 III 1100 VII ff1 ilfi II HID II DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV XO03797:09* u, 1 U21 2 4 1 U1 2 U2 1 U1 1 U2 1 U1 1 U2 1 1 10 U, 3 U2 1 *P 0119 INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 15 VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash ❑AMENDED YR 2025I 2025-00026130 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I ® ❑ RELATED ®Y 0 N 04 25 2025 ❑AM ❑YES ®NO U1 —< S SPRING ST Elgin02:39 _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION ITl FT!MI N E S W D U PAG E CT COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 15 ' ❑ Kane HIT&RUN ❑V ® N WITH VEHICLESOT, INVLD ❑ STOPPED U2 --I Igi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUCE 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C) FOR DAMAGEDAREA(S) FROM TOWED U1 I� Beniot. Mary.A. 0 4 / yr 13-UNDER CARRIAGE ©,I �:: FIRE 0 IE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 0 171 F 2 SY is-OTHER 4 ❑Y ®SNE❑UNK VEH. O AT CRASM IN H O 99-UNKNOWN 916•TOP 3 `Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s it B �i COM VEH 0 0 1 0 H 1- BARTLETT IL 60103 0 1 0 FIRST CONTACT 11 7_: __s *IIYes.See Sidebar U1 ZDG49597 IL 2025 REAR TELEPHONE IL D 0 5N1 DL1 GS5PC346698 Berkly One ❑Y ®N U2 93 . m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same PA04296190 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y El 2 0 p; DRIVER ❑ PARKED 0 DRIVERLESS 0 FED ❑PEDAL 0 EWES 0 NMv 0 KCV 0 Dv !1 9 yf 7 Ford Explorer 2017 oo-NONE ,,"1 Qi-O DUE TO CRASH rg ❑ 6 xi 0 13-UNDER CARRIAGE 10 i I. E FIRE 0 ® U2 C c F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistrac on Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i B i.'.,_4 COM VEH ❑ ® U1 CO FIRST CONTACT 1 7 _, _5 •IfYes.See Sidebar C ELGIN IL 60120 0 1 0 MP14956 IL 202 I Si)0 M IL D 0 1 FM5K8ARDGC78214 Charter Fire Insurance Co ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 City of Elgin.City 8109160P901 BAG $ 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) W 04 / U1 1 D / / 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 11 4 04,25 /2025 02 39 ®AM 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 7 n T 0 2 ❑ 2 99 + ! ❑PM• D Construction X Z 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 —a ARREST NAME Beniot. Mary.A. 11-901.01 1549000062 / ! El PM 1 1 1 4 El 0 CITATIONS ISSUED SECTION CITATION NO. ROAD CLEARANCE TIME PENDING SLMT o, N ® 0 AM t 2 ElARREST NAME 04 r 25 ,2025 03 00 0 PM ❑Unknown work zone type U1 25 2 2 3 El CO ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 25 1549-Brown. Bryan tot 05 , 13,2025 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 N ADDITIONAL UNITS FORMS. r ----r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z +� 1 I 1 s weightrating than pounds(example:truck or truckrtrarler -< , I more10,Has awe i- ;.--_.r-_--; N •?�i` ( combination):or -I OP 7�'Ny INDICATE NORTH C 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 O. T, W 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O } } . transporting employees in the course of their employment(example:employee X Durl8g6?COurt transporter-usually a van type vehicle or passenger car):or co c L L.___a__ 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y l } } } for direct compensation(example:large van used for speific purpoe):or the driver. O I 7 .�.a &r,. •D < .I. t i i L 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m J placarding(example:placards will be displayed on the vehicle). D Y'',A —I w (A, CARRIER NAME Z 1)�1 - ._ ADDRESS 0 ,i_ r V) Nat?b7acele n CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate 0 Intrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other --- --4. USDOT NO. ILCC NO. m XI Source of above z . If Yes,Name on placard 0 4 digit UN NO. 1 digit Hazard class No. 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 E 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 VIN 1 m co LOCAL USE ONLY TRAILER VIN 2 m 0 TRAILER WIDTH(S) 0-96" 97-102" >102' -n TRAILER 1 0 0 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Silver Black u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® Redmons/Police Department VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE