HomeMy WebLinkAbout2025-00029006 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 0110110011 0
liii lU Dl III 0
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00 976T'
u, 9 U2 1 1 1 U,99 U2 1 U199 1_12 U,99 U2 1 1 9 U1 99 U221 *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 1215501-$1.500 ❑ON SCENE 7
VEHICLE/PROPERTY ❑OVER$1,500 ®NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 2025I 2025-00029006 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 71
214 WALNUT AVE Elgin08:52
® ❑ RELATED ❑Y ®N 05 06 2025 DAM ❑YES El NO U1
_ g PRIVATE mo /day/yr ®PM FLOW CONDITION MCOUNTY PROPERTY ''Y ❑N DOORING ❑y #OF MOTOR ❑SLOW 15 u)
❑ FT/MI NESW Kane HIT ®Y ❑ N WITH VEHICLES INVLD ❑ STOPPED U2 --I
ID AT 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 NW 0!Cy 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
/ ! FOR DAMAGEDAREA(S) FRO TOWED U1 0
Unknown.O. Unknown Unknown 00-NONE it.. 12 , OUETOCRASH ❑
NAME{LAST,FIRST.M) mo yr 13-UNDER CARRIAGE 10 ! 2 FIRE 0 IE <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) U2
9 9 SYSTEM IN 9 ENGAGED 9 15-OTHER 916-Top S DISTRACTED ❑ 0 _
❑Y ❑N ®UNK VEH. AT CRASH ®-UNKNOWN 6 4 `Distraction Vatuc 9 ALGN
'a- CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF il L 6 ji COM VEH 0 El 1 00
I— FIRST CONTACT 99 7_:—, 5__ *IIYes.See Sidebar U1
0 9 9 UNKNOWN "E
2 Z
_ TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1)
UNKNOWN ❑Y ❑N U2 I—
SI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same UNKNOWN 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
'‘.3D Y°®N
5, 0 DRIVER I} PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 M/v 0 Ncv 0 Dv
yr Mitsubishi Eclipse 2023 00-NONE ,t_ t2.._, DUE TO CRASH ❑ 2 77
0 13-UNDER CARRIAGE 101 2 FIRE 0 ® U2 C
II SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN 0 ENGAGED 0 15-OTHER O9 16.70P 3 0 ® SPDR 0
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value U1 0 -
POINT OF 6 I -4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6 l!._ C.OM VEH ❑ ® CO
~ DQ44404 I L FIRST CONTACT 9 7 _, _5 •If Yes,See Sidebar C
0
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
JA4ATWAA4PZ001125 Allstate ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Matsas.Graci.G. 912970684 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (0081 (SEX) {SAFT) (AIR) OM (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{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 05,07 l2025 02 33 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 30
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 0 30 99
N 3 0 CITATIONS ISSUED 0 PENDING + ! 0 PM- ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 7
z
-a ARREST NAME / / ID '
o u ® 11 5 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT
,
15
t 2 0 ARREST NAME AM
7 1 r ❑❑PM ❑Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 15
558-Lara. -izette 701 - / / 0 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 -<
c ` --I -' r INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ } (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
__ __ I 4. Is used or desi nated to trans rt between 9 and 15 C
r„ } } } g po passengers,including[he driver, to
2 for direct compensation(example:large van used for specific purpose):or O
} } } _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle).
—1
CARRIER NAME Z
"" ADDRESS
Not ToSoak , CITY/STATE/ZIP n
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
%I. --- --1 - % % % USDOT NO. ILCC NO. rn
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
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 0 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE