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HomeMy WebLinkAbout2025-00027679 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111 III 11 IIIIII OHI U� 11111U� 0011101111ODDD DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X0038O4550 u, 1 U21 1 1 2 U1 2 U2 1 U1 1 U2 1 U1 1 U2 1 1 13 U, 15 U2 1 *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 El$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 2025-00027679 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn ® ❑ RELATED ❑Y ®N 05 02 2025 E�IAM ❑YES ®NO U1 -< W HIGHLAND AVE Elgin07:59 _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m FT!MI N E S W LARKIN AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n ❑ 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 Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0 lacv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) 4 0 Y N 0 5 ! yr O3-UNDER CARRIAGE ©i ! 2 FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 4 M M 2 9 El ®SNE❑Uis-OTHER NK VEH. O ATCRASHIND O 99-UNKNOWN 9 16•TOP 3 `Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, i�6 �i COM VEH 0 Ea 2 O ELGIN I L 60120 B 1 0 FIRST CONTACT 11 7_: __5 *Ilyes.See Sidebar U1 Z DD47521 IL 2025 REAR TELEPHONE IL D 4S3BL616457222089 Kemper ❑v ®N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR co Elgin Fire Nava. Marisol 12RA000011991 2 m `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER RESPONDER > Refused ❑Y ® N 2 g DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑NW 0 KKv ❑DV !y 1 9 9 0 Chevrolet Trax 2024 00-NONE O Q�-_, DUE TO CRASH 0 ❑ 2 x o 13-UNDER CARRIAGE 10( I 2 FIRE ❑ El U2 C F 2 8 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distrac on Value 9 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 6 1:, COM VEH ❑ ® U1 CO FIRST CONTACT 11 7� __5 •(ryes.See Sidebar m ELGIN M IL 60123 B 1 0 EG23779 IL 2025 IL D KL77LHE23RC091756 State Farm ❑Y ®N RDEF Xl EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Elgin Fire Same 0688822-SFP-13 BAG E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 < Sherman RESPONDER U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 2 6 05 / :A / / UI 1 D / / 2 0 U EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur 0 Y U2 Z N 1 ® 11 1 5/ ,/2 !25 08 00 ❑PM 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 C) 2 0 20 28 5/ (/2 !25 08 01 ❑PM ❑Construction * <w 3 0 ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 z J ®AM ❑Maintenance U2 o ® 11 1 ARREST NAME Saldana. Kristofer 11-601-Ax 3400134 5/ (/2 !25 08 06 ❑PM• El Utility SLMT l$!CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME o N 0 AM 30 r 2 El ARREST NAME Saldana. Kristofer 11-709-A 3400135 ( ! PM 0 Unknown work zone type U1 2 2 3 0 OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30 340-Phillips. Kathryn 600 368-Davenport 6/ ( 0/ (025 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 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- i•----.-----; Not To Scale I - } INDICATE NORTH combination):or -I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C 0 - (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 r -I-- --i I. } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver, to for direct compensation(example:large van used for specific purpose):or o __ ___„‘ L ` 11 — t i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m `----�`----' r r ,..+, placarding(example:placards will be displayed on the vehicle). ;p D 1j CARRIER NAME Z m y '- O r j f I t� rewxrorera.wi. i. ADDRESS > _ ra rv++.'.0".- CITY/STATE/ZIP 0 - MOTOR CARR.ID 0 Interstate El Intrastate C 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 . —I Were HAZMAT placards on vehicle? 0 Yes 0 No = If Yes,Name on placard O 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 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 Blue Blue 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