HomeMy WebLinkAbout2025-00028696 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111 III 11 IIIIII UHI
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) (83B Injury and for Tow Due To Crash
0 AMENDED YR 202512025-00028696 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED ®Y 0 N 05 06 2025 ❑AM ❑YES N NO U1
ST CHARLES ST Elgin02:23
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W BENT ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 3 Cl)
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 —I
O AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Qg)DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
FOR DAMAGEDAREA(S) FRONr TOWED U1 Q
Brock. Desmon.T. 0 1 /
yr 13-UNDER CARRIAGE I FIRE ❑ N
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O 2 DISTRACTED 0 0 U2 0 m
SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3
M 2 4 0 0 =
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 9 ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 0 i� �'.4 COM VEH 0 j$J 1 C)
H Z South Elgin I L 60177 0 1 0 DC17487 IL 2025 FIRST CONTACT 9 O7 _;REAR
__5 *Yves.See Sidebar U1
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TELEPHONE
IL D 0 19XFB2F83DE047131 Progressive ❑Y Il N U2 m
B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 988381662 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER XI
Refused 0 Y El 2 0
N DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL ❑EWES 0 MAV 0 NCV 0 DV
$ !1 9 9 3 Toyota Sienna 2010' 00-NONE O, Qj.O DUE TO CRASH rg ❑ 2 x
O yr 13-UNDER CARRIAGE FIRE 0 ® U2 C
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F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 1,6-TOP 3 X
❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 9 0
I. 4 COM VEH 0 N U1 co
i1 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF FIRST CONTACT 12 8 7. s-5 •If Yes.See Sidebar
— Geneva IL 60134 0 1 0 EX55708 IL 2024 REAR 0 Si)
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IL 0 5TDYK4CC8AS290397 American Alliance ❑Y N N RDEF Xl
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same I LAA101239700 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (DOB) (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 4 05(06 l2025 02 42 ®pm in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1 �
v 2 0 2 99 05,06 (2025 11 42 ❑PM ❑Construction >F
R O 0 ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
3 ❑AM 0 Maintenance U2
a1 ® 11 4 ARREST NAME Brock. Desmon.T. 11-901-A W1500000344 05(06 l2025 02 48 Igi pM SLMT
o N
❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility
0 Am
r 2 0 ARREST NAME 05/06 l2025 03 23 ®PM 0 Unknown work zone type U1 35
x T
n OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ — ❑AM Workers present? ❑Y 35
1500 Chen. Marie 401 , ❑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
0. ..) 1. Hasa weightra g ore than pound { a p :truck or truckrtrarler -<
tin m 10000 s ex m le} ' ' Ir INDICATE NORTHp0
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
C
} I - i. e. (example:shuttle or charter bus):or 0
Not To Scale J 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O
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I. } } } transporting employees in the course of their employment(example:employee
�� 1 I `�- transporter-usually a van type vehicle or passenger car):or CO
L L.__-a__ I 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or o
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L L.._-a____. i 1M111 - t i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle).
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,j CARRIER NAME Z
ADDRESS
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CITY/STATE/ZIP 0
I i. i. i. i. MOTOR CARR.ID 0 Interstate 0 Intrastate
0
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
;_...Y. ._; - USDOT NO. ILCC NO. m
XI
Source of above 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
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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
Bronze Green.Light
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
Arties/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 Mies/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE