HomeMy WebLinkAbout2025-00028222 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003609778.
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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. TRAP/ '
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER 61,500 El NOT ON SCENE(DESK REPORT) El B Injury and/or Tow Due To Crash
0 AMENDED YR 2O25I 2025-00028222 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I
OAKLEY AVE Elgin01:15
® ❑ RELATED ®Y 0 N 05 04 2025 ❑AM ❑YES El NO U1 -<
_ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION III
FT!MI N E S W HUBBARD BBARD AVE COUNTY PROPERTY ❑Y ® N DOORING ID #OF MOTOR ID SLOW 1 (/)❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ® FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑uuv ❑!CV ❑ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
0 7 +
yr 13-UNDER CARRIAGE I FIRE 0
NI STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O 2 DISTRACTED 0 0U2 2 I'T1
M 2 6 SYTM IN ENGAGETHER
❑Y ®SNE❑UNK VEH. 0 AT CRASHD 0 99-Uis-ONKNOWN 00-TOP 3 ,Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF it 6 I'.4 COM VEH 0 lgl 1 0
~ ELGIN I L 60123 C 1 0 FIRST CONTACT 9 t _; __5 •((Yes.See Sidebar U1 0
Z E628745 IL 2026 REAR
TELEPHONE
IL 0 J N8AZ2N E6F9081122 ALLSTATE ❑Y ®N U2 I '
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 99 9 Same 912090637 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Provena St.Joseph ❑Y ® N 2 .012
p; DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑row 0 Ncv ❑Dv
yr Ford Fusion 2013 00-NONE O, 0i.O1 DUE TO CRASH rg ❑ 2 x
0 13-UNDER CARRIAGE 10 i C 2 FIRE 0 ® U2 C
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M 2 5 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X
❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistraglon Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s_i� 4 COM VEH ❑ ® U1 CO
FIRST CONTACT 12 Y�� =5 •)ryes.See Sidebar C
ELGIN IL 60123 C 1 0 DY47820 IL 2025 I N
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IL D 0 3FA6P0H91DR144533 AMERICAN ALLIANCE ❑Y 0 N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire 99 9 HERNANDEZ. DENISE ILAA-0822094-02 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE;ZIP
U1 =
(UNIT) (SEAT) (DOBi (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
1 3 08 /
D
/ / 2 0
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 4 51 /12 /25 01 15 ®PM AM in a Work Zone? ®N DIRP D
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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 2 99 51 )12 /25 01 25 ®PM ❑Construction
<w 1 3 0 El CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
z J ❑AM 0 Maintenance U2
o ® 11 4 ARREST NAME Blalark.Walter. H. 11-901-A 1551000075 51 /12 /25 01 31 Igi PM SLMT
o N
0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' El Utility
AM
t 2 El ARREST NAME 51 /12 /25 02 01 0 PM 0 Unknown work zone type U1 3O
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM workers present? ❑Y 30
1551-Dede.Joseph 601 61 / 01 /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 -<
c ` -' -' r INDICATE NORTH combination):or —I
0 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver n
_ } (example:shuttle or charter bus):or
X
l- <----- ----; - } } } transporting employeened to s the course or fewer passengers
rhea emaployment nd operated
xample:ernaployeener
--1 `1 Not To Scale t ansporter-usually a van Type vehicle or passenger car):Or w
L -----}----; I - } } } 4. Is used or designated to transport between 9 and 1 ssen rs,including the driver,
l'i for direct compensation(example:large van used fors specific purpose):or O
L L____a____. _ t i. i L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
i .I . -- ) placarding(example:placards will be displayed on the vehicle). XI
— - I I - __
v CARRIER NAME- -I
7
lag,. _ 1 ADDRESS
ro- crideniLlwaret
(/)CITY/STATE/ZIP T.
MOTOR I. CARR.ID 0 Interstate 0 Intrastate
I r ❑ Not in Comm./Govt. 0 Not in Comm./Other
------- --1 - USDOT NO. ILCC NO. rn
XI
Source of above z
. ❑ Yes 0 No 0 Unknown g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash?
❑ Yes II No ElUnknown 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
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LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Black Green
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 DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE—LOAD TYPE