HomeMy WebLinkAbout2025-00028447 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XO03609T4
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INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00028447 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 71
180 S STATE ST Elgin03:06
® ❑ RELATED ❑Y ®N 05 05 2025 DAM ❑YES ®NO U1 -<
_ PRIVATE mo /day/yr ®PM FLOW CONDITION Ill
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ FT 1 MI N E S W Kane HIT ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I
El AT RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
1 , FOR DAMAGEDAREA(S) FROPtf TOWED U1 Q
Unknown.O. Unknown Unknown 00-NONE it_ t2 , DUE TOCRASH 0 NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE i FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) OO. 2 U2 2 <
9 9 SYSTEM IN 9 ENGAGED 9 15-OTHER 916-TOP 3 DISTRACTED 0 ]$I =
❑Y ❑N ®UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN
6 4 COM VEH 0 ga
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _.I�6 �i,_ 1 0
0 9 0 FIRST CONTACT 10 7 ;REAR _5 *II Yes.See&debar U1
2 Z ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1/
Unknown ❑Y ❑N U2 m
13 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
r RESPONDER®
9 yf 6 Honda Accord 2000' 00-NONE 11_"1 QI O DUE TO CRASH ❑ 2 xr
o 13-UNDER CARRIAGE 10( 2 FIRE 0 ® U2 C
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 91,6-TOP 3
❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value g g
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8
-il _ Il, 4 COM VEH ❑ ® U1 CO
FIRST CONTACT 1 YA—O__{ _s •• •IfYes,See Sidebar
. LE GINZ IL 60120 0 1 0 CN39004 IL I:EaR c
9 cn
M
IL 0 JHMCG5655YC039541 StateFarm ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Rivera-De La.Carmelo.O. 2112825SFP13 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJ) (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 05/05 /2025 03 06 ®pm 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 �
2 0 04 99
N 3 0 0 CITATIONS ISSUED 0 PENDING •
+ ) 0 PM- El Construction
SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
-a, ARREST NAME / / ID PM '
oN ® 11 1 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT
r 2 ❑ ARREST NAMEAM
T 1 / ❑❑PM ❑Unknown work zone type
U1
n OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? 0 Y 30
1530 Soto.Oscar 701 , / ❑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••--, , Unit 2 : A CMV is defined as any motor vehicle used to transport passengers or property and: Z
i 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
` ` --I -4. s •js ~ I r INDICATE NORTH combination):or .Z-1
�,'1 / N BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
;)-_ _ (example:shuttle or charter bus):or 0
3. Is designed to carry15 or fewer passengers and operated a contract carrier O
< }.___A.._.� , I - y } } } transportingemployees In the course of their g employment(example:employee
0 transporter-usually a van type vehicle or passenger car):or co
L }-----}----; - } } 1. 0
4. Is used or designated to transport between 9 and 1 passengers,including the driver,
for direct compensation(example:large van used fors specific purose):or
` .I. a)* Not To Scale ( - ` ` } m
_ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
.. J placarding(example:placards will be displayed on the vehicle). m
0
i __
0. I CARRIER NAME Z
rq
I - ADDRESS 0
T.
C)
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate ❑ Intrastate
CT ❑ Not in Comm./Govt. Not in Comm./Other S?State?St; _ _Y_._.;
USDOT NO. ILCC NO. m
XI
Source of above z
. ❑ Yes 0 No 0 Unknown g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash? A
❑ Yes No ❑ 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'; 0 Yes 0 No 2
TRAILER VIN 1 m
co
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
Black Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 4 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE