HomeMy WebLinkAbout2025-00027086 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 0110110011 01111111 10100 0
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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 1215501-$1.500 ❑ON SCENE 7
VEHICLE/PROPERTY ❑OVER$1,500 lgl NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 2025I 2025-00027086 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m
1475 LARKIN AVE El In09:30
® ❑ RELATED ❑Y ®N 04 23 2025 ®AM ❑YES ®NO U1
g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
_
COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ FT/MI NESW Kane HIT ®Y ❑ N WITH VEHICLES INVLD IN STOPPED U2 --I
&RUN
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Q83 DRIVER I] PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NOV 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
/ ! FOR DAMAGEDAREA(S) FRONT TOWED U1 0
NAME(LAST,FIRST,M) Unknown. Unknown.0. mo yr Unknown Unknown 00-NONE
OUETOCRASH ❑11 12 - EN
13-UNDER CARRIAGE 10 i 2 FIRE 0 IE <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 m
9 9 SYSTEM IN 9 ENGAGED 9 15-OTHER 9 16.TOP 3 _
❑Y ❑N ®UNK VEH. AT CRASH ®-UNKNOWN $ 4 `Distraction Value 9 ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF L s �i COM VEH 0 j$J 1 00
I• 0 9 9FIRST CONTACT 99 7_i __5 *IIYes.See Sidebar U1
ZUnknwon ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1
Unknown ❑Y ❑N U2 I—
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same Unknown 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y 23N 9 99 G0)
0 DRIVER X. PARKED 0 DRIVERLESS 0 FED 0 PEON. 0 EWES 0 NMV 0 KCV 0 DV
yr 12 _ C
0 13-UNDER CARRIAGE 10 1 2 FIRE ID El U2
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR 0
SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP 3 9 X
a ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `(Distraction Value
POINT OF 8 ) -4 Ut
CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR O S l},_ COM VEH ❑ ® CO
FIRST CONTACT 7 7 ._, _5 •IfYes.See Sidebar
CX65411 IL 2024 I:EaR 0 N
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
3C4PDDGG8HT554236 Unique Insurance 0 Y ®N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
Same I LP2810045 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
❑Y RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 18 5 04,29 /2025 05 04 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 0 18 18
N 3 0 0 CITATIONS ISSUED 0 PENDING + / ❑PM• ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5
z
—a, ARREST NAME / / 0 PM '
o u ® 11 5 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
SLMT
15
T 2 ARREST NAME AM
T 1 r ❑❑PM ❑Unknown work zone type U1
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n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 15
558-Lara. _izette 602 391-Jacobucci r / ❑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-----' INDICATE NORTH combination):or more than pound (example:truck or truck/trailer
1. Has a weight rating10 000 5
tion): -I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
,�. _ (example:shuttle or charter bus):or 0
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
C
L L.___a__...I 3 I. •4. Is used ordesi natedtotrans rtbetween9and15passengers,includingthedriver,
I _ } } } for direct compensation(example:large van used for speific purose):or 0
L -a-___.I — Si t i. < i. 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
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placarding(example:placards will be displayed on the vehicle). ,Zmt
—1
— CARRIER NAME Z
ADDRESS 0
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CITY/STATE/ZIP g
Nor To Swh
MOTOR CARR.ID 0 Interstate ❑ 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
. 0 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
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
Silver Black
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: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE