HomeMy WebLinkAbout2025-00027733 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003606845
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 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 2
VEHICLE/PROPERTY ®OVER$1,500
El NOT ON SCENE(DESK REPORT)
El AMENDED ElB Injury and for Tow Due To Crash YR 2025I 2025-00027733 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 mHIGGINS RD Elgin 01:14
® ❑ RELATED ®Y ❑N 05 02 2025 ❑AM ❑YES ®NO U1 -<
g PRIVATE mo !day!yr ®PM FLOW CONDITION m
FT!MI N E S W N RANDALL RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 2 co
❑ Kane HIT&RUN M V ❑ N WITH VEHICLESOT,
INVLD DO
STOPPED U2 -I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EOUES 0 Nuv 0!Cu 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 7 0
FOR DAMAGEDAREA(S) FROM TOWED U1
Unknown. Unknown. U. ! / T Dodge Journey 2017 00-NONE „ 12 , DUE TOCRASH ❑ EN
NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE NI
101 ! 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 14 U2 7 m
9 SY9 ❑Y ❑SNEM®UNK VEH. 9 AT CRASHD 9 99-UNKNOWN 9 16•TOP 3 ,Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 i L S 4 COM VEH 0 El 1
H 1 Unknown UnknowrUnknown 0 9 0 Y921979 IL FIRST CONTACT 99 7_; _5 *If Yes.SeeSideDar U1
0
REAR
c Z E
TELEPHONE
UNK. Other 9 3C4PDCAB1 HT644254 Unknown ❑Y ❑N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Dugli.Jason Unknown 1 rn
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
t RESPONDER - Ai
m g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑NMV 0 NO! ❑Dv
� !1 9 yf 2 Dodge Ram 2500 2016 00-NONE 11-.. t2...0 DUE TO CRASH ❑ 2 x
0 13-UNDER CARRIAGE 10 2 FIRE 0 El U2 C
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistrac on Value 9
POINT OF 8 i1�i-4 COM VEH ❑ ® U1 W
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR S
FIRST CONTACT 1 Y _5 • •It Yes,See Sidebar
— Sandwhich IL 60545- 0 1 0 1809074B IL REAR 0 C
D
IL D 0 3C6UR5CL2GG255448 Progressive ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 972251928 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 9 05,02 ,2025 01 14 ®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 C)
2 2 28 05,02 ,2025 01 14 PM
® • ❑Construction *
R 3 0 ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
AM
-a u SLMT ARREST NAME 05,03,2025 ❑❑PM ❑Maintenance
1 ® 1 1 4 Utility
MT
o SECTION CITATION NO. ROAD CLEARANCE TIME Ely
❑CITATIONS ISSUED PENDING
t 2 ElARREST NAME 05102 ,2025 01 14 ®PM 0 Unknown work zone type U1 45
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ ❑AM workers present? ❑Y 45
1527-Juarez.Jorge 901 391-Jacobucci , , ❑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
�____r____; �, �I � _ I combination)ghtratingmorethan10,000pounds(example:truckortruck/trailer
NDICATE NORTH
or -I
am I•JI I I II € BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
iI' I..I I I' 1 (example:shuttle or charter bus):or 0
8l. 11 I r r 3. Is designed to carry15 or fewer gpassengers and operated by a contract carrier 0
N3Ra OYNnC -�I I I I % t'1°"""rr"" _ - } } . transporting employees in the course of their employment(example:employee X
vo.L transporter-usually a van type vehicle or passenger car):or w
a t� c: O.
i. •:. .}----; <, <_ . . p - } } 1 •4. Is used or designated to transport between 9 and 15 passengers,including the driver, N
j for direct compensation(example:large van used for specific purpose):or
s s % 4 4 4n
L L____a____. - ! i i t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)thatrequires m
_ r9 I
r y placarding(example:placards will be displayed on the vehicle). XI
.y ..I... i,l I r N.?Rendeima CARRIER NAME Z
N.9RwpcIRRO r I AI A I fr I _ __ ADDRESS
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j I h I CITY/STATE/ZIP g
I i I- MOTOR CARR.ID ❑ Interstate El Intrastate
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l I r l ❑ Not in Comm./Govt. 0 Not in Comm./Other
--- --1 - USDOT NO. ILCC NO. m
XI
Source of above z
. Form Number
m
Xl
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
v
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 Gray
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