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HomeMy WebLinkAbout2025-00024644 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 01101100 VI 0101100 III DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003793326 u, 9 u210 1 1 1 U1 2 U2 1 U199 U213 U,99 U2 1 4 9 u, 1 U221 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW ' Elgin Police Department ONE PERSON'S ®5501-51.500 ®ON SCENE 1 VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 2025512025-00024644 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 71 604 LINCOLN AVE Elgin06:18 ® ❑ RELATED ❑Y ®N 04 19 2025 ®AM ❑YES El NO U1 —< _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION MCOUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n ❑ FT!MI N E S W Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Q83 DRIVER O PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C) ! ! FOR DAMAGEDAREA(S) FROM�TOWED U1 Q NAME(LAST,FIRST,M) Unknown.O. mo Unknown Unknown 00-NONE 11_ 2 T,a:/ouETOCRASH ❑ EN 13-UNDER CARRIAGE 10 i , 2 FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ ga U2 2 m SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 9 9 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s_iL S ii,4 COM VEH 0 j$J 1 0 ~ 0 9 0 FIRST CONTACT 1 7_; _5 *Irves.See Sidebar U1 REAR 2 Z ' E TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 11/ UNK ❑Y ❑N U2 M 5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m co 1 99 9 Same UNK 1 rn `o HOSPITAL(TAKEN TO) INCIDENT IF`V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER en Refused ❑Y ❑ N 99 0 0 DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 iiAV 0 NCv 0 CIRCLE NUMBER(S) U1 DV yr _ 13-UNDER CARRIAGE 10 ©I{, 2 FIRE ❑ El C SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR C) SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 9 0 X a ❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN *0istrac Dn Value POINT OF S ) 4 Ut N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR S COM VEH ❑ ® CO H EQ74229 I L FIRST CONTACT 7 O7 ,�=QI_5 •If Yes.See Sidebar Si) REAR 0 M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 KL1TG66E79B656039 The General ❑Y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 = 1 99 9 Guasamucare.Slyvana• D. 1 BIL8063700 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) ISEATI (008) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) U2 996 r m ##occs y 71 / / U1 1 D / / 0 EV MOST EVNT DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 18 9 04,19 /2025 07 00 ®❑AM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 Si 2 0 18 18 N 3 ❑ ❑CITATIONS ISSUED 0 PENDING + ❑PM• ❑Construction SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 7 —a ARREST NAME / / ❑PM ' 1 ® 1 1 1 ❑CITATIONS ISSUED PENDING UtilitySLMT , o u SECTION CITATION NO. ROAD CLEARANCE TIME 0 AM 25 t 2 ElARREST NAME 04 r 19 /2025 07 00 [M PM 0 Unknown work zone type U1 n 7 OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? 0 Y 25 435-Mahan. David 201 275-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 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----; ( combination):or —I �I +�+ I INDICATE NORTH BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C _ } (example:shuttle or charter bus):or X L A 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 transporter-usually a van type vehicle or passenger car):or w L L.___a__-_� 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including C} } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or O L L--_-a.---. u,a3_ -wmz fL. - - - - t i I 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires UM , , , , placarding(example:placards will be displayed on the vehicle). XI —1 I tfs.rdtwa I CARRIER NAME Z ADDRESS 0 w u Not To Scale r CITY/STATE/ZIP 0 MOTOR CARR.ID 0 Interstate 0 Intrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other ‘I. - --1 - USDOT NO. ILCC NO. m XI Source of above z . ❑ Yes II No ❑ Unknown A 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 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 Yellow u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 9 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