HomeMy WebLinkAbout2025-00026957 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
0 AMENDED YR 202512025-00026957 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I
® ❑ RELATED ®Y 0 N 04 29 2025 ®AM ❑YES ®NO U1
HIAWATHA DR Elgin08:14
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FTlMI N E S W CONGDON AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 u)
❑ Cook HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUES 0 Nuv 0 NCv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 n
FOR DAMAGEDAREA(S) FROM TOWED U1 I�
NAME(LAST,FIRST,M) HORNE. KIMBERLY. E. mo 0 6 / !1 9 9 2 Chevrolet Trax 2017 00-NONE „_ Oi_, DUE TOCRASH ❑ VI
13-UNDER CARRIAGE 10 , p FIRE 0 NI
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 3 I<T1
F 2 4 SY❑Y ®SNEM DUNK VEH. O AT CRASH 0 99-UUTHER NKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN
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r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 7 :il 6 4 COM VEH 0 j$J 1 0
~ ELGIN I N I L 60120 0 1 0 FIRST CONTACT 12 7_;{ _5 *Ir Yes.See Sidebar U1
Z AE31535 IL 2025 REAR
7 TELEPHONE
IL D 0 3G NCJ LSB7H L278801 STATE FARM ❑Y ®N U2 Rri
12 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 2409207SFP13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 9 2 0
g DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 NUV 0 Ncv 0 Dv CIRCLE NUMBER(S) U1
!1 9 9 0 Hyundai Santa Fe 2018 00-NONE 1i_` 12�"_, DUE TO CRASH rg ❑ 2
0 13-UNDER CARRIAGE o I 2 FIRE ❑ ® U2 C
c
M 2 6 SYSTEM IN 0 ENGAGED 0 15-OTHER O9 16.70P 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracii n value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 0'i !;_4 COM VEH ❑ ® U1 CO
FIRST CONTACT 9 7 _, _5 ••)ryes, •See Sidebar C
Franklin Park IL 60131 0 1 0 FC91751 IL 2025 I 0 Si)
IL D 0 SXYZTDLB2JG568944 AMERICAN ALLIANCE ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same I LAA-1005676-01 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused ID RESPONDER Y ® 9 u1 =
(UNIT) (SEAT) (DOB1 (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME(!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 6 09 / M 11 3 B 1 0
m
/ / #OCCS >
71
/ / u1 2 m
/ / 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
El N 1 ® 11 4 41 ,91 l025 08 14 0 AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1 C)
2 0 2 28 41 ,91 ,025 08 14 0 PM 0 Construction *
CV O 0 xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
3 ®AM 0 Maintenance U2
— N a, ARREST NAME HORNE. KIMBERLY. E. 11-901-A 374001316 41 ,91 ,025 08 20 ❑PM SLMT
1 ® ElUtilit 11 4 0 CITATIONS ISSUED SECTION CITATION NO. ROAD CLEARANCE TIME
PENDING
o y
AM U, 30
t 2 ❑ ARREST NAME 41 ,91 ,025 08 20 [M PM ❑Unknown work zone type
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 30
374-Rizzu-o. Michael 201 368-Davenport 61 , 12 ,25 01 30 ®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 truckrtrailer -<
c ` --1 -' r INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
n 0 _ (example:shuttle or charter bus):or
CO
L NOt TO saaw 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
- } } } transporting employees In the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or
C
L 4. Is used or desi designated to trans transport between 9 and 15 passengers,including N-- -- mwao�o�.. uwr.2 - } } } g po passen rs,includi the driver,
for direct compensation(example:large van used for specific purpose):or
__ __ 1 i i L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
=� placarding(example:placards will be displayed on the vehicle). ;p
UNIT' \ D
1 T - {
\ CARRIER NAME Z
N ADDRESS 0
C)
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate El Intrastate
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
i— --- --1 - USDOT NO. ILCC NO. m
XI
Source of above z
. ❑ Yes 0 No 0 Unknown g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash? A
0 Yes No ❑ 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 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Gray Black
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 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE