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HomeMy WebLinkAbout2025-00026971 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 1 flh1l1ll 111111011 DRAC TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANV *X003600399* u, 1 U21 3 4 1 U1 7 U2 1 U, 1 u2 1 u, 2 u2 1 1 11 U1 15 U211 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 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$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash 0 AMENDED YR 2025I 2025-00026971 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 r1 ® ❑ RELATED ❑Y ®N 04 29 2025 ®AM ❑YES ®NO U1 -< N STATE ST Elgin09:21 _ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m FT!MI N E S W TOLLGATE RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLESOT, INVLD ❑ STOPPED U2 —I Igl AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ® FREE FLOW # LNS 0 Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 6 n 0 4 / yr 13-UNDER CARRIAGE ©,I �:: FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 6 m M 2 SYTM IN ENGAGE15-OTHER 5 ❑Y ❑SNE®UNK VEH. 9 ATCRASHD 9 99-UNKNOWN 916•TOP 3 `Distraction Value 9 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF & i�S 4 COM VEH 0 j$J 1 0 ~ TinleyPark I L 60478 0 1 0 FIRST CONTACT 12 7_: __5 *lI Ves.See Sidebar U1 ZDX55684 IL 2025 REAR TELEPHONE IL D 2C4RDG BG6G R276620 Allstate ❑Y ®N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Chicmed Transportati 811784589 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 XI x DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMV 0 NOV 0 Dv yr!1 9 5 5 Nissan Murano 2010' 00-NONE O-i QNT!'-O DUE TO CRASH rg ❑ 2 x o _ 13-UNDER CARRIAGE 10( I 2 FIRE ID El U2 C M 2 5 SYSTEM IN 9 ENGAGED 9 15-OTHER 9,16-TOP 3 X ❑Y ❑N ®UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S 1 S ./. C.OM VEH ❑ ® U1 CO FIRST CONTACT 6 O7 :__Q)OS •If Yes.See Sidebar C ELGIN IL 60123 B 1 0 Q372733 IL 2025 FIRST Si)0 Z IL D JN8AZ1 MU6AW004067 State Farm ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Elgin Fire Same K644372C2513 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Sherman 0 Y°ND O N U1 = (UNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJ) (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 41 /91 /025 09 21 ®❑AM in a Work Zone? ®N DIRP co 1 t PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME 0 AM If YES check one below: U1 1 C) T 2 0 10 28 1 / ❑PM 0 Construction X R 3 0 ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 z J ®AM ❑Maintenance U2 - ® ElUtilit a, ARREST NAME Ayesh. Isnad.A. 11-601-Ax 410000718 4/ /9/ /025 09 34 ❑pM o SLMT U 11 1 CITATIONS ISSUED PENDING o N SECTION CITATION NO. ROAD CLEARANCE TIME y AM 45 t 2 El1 1 1 ARREST NAME 4/ /9/ /025 10 22 MPM 0 Unknown work zone type u, 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 45 410-DeLeon.Jessica 501 275-Engelke 5/ / 0/ /025 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 I I I I I } :+ I I I I I 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< 1 E combination):or —I ' ' N r INDICATE NORTH P3 1ewear. BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C — - } (example:shuttle or charter bus):or T, 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 lP L }-----}----; rb,m ABg, I. } } 4. Is used or designated to transport between 9 and 15 passengers,including the driver, for direct compensation(example:large van used for specific purpose):or __ _a____� N t l. I 1 t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)thatrequires , O -u �.q placarding(example:placards will be displayed on the vehicle). XI r --I _ CARRIER NAME Z ADDRESS 0 T. CITY/STATE/ZIP n 5 - i. r MOTOR CARR.ID 0 Interstate ElIntrastate Y USDOT NO. I I T I I ❑ Not in Comm./Govt.. Not in Comm./Other0 ILCC NO. m XI Source of above z . If Yes,Name on placard 0 4 digit UN NO. 1 digit Hazard class No. Xl Xl 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 g 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 Z TRAILER 2 ❑ 0 0 o u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w White Tan 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 DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE