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HomeMy WebLinkAbout2025-00030038 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 6 Sheets 01111101111 I01101100000000* III II II DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003615188� u, 9 U2 3 4 1 U199 u2 U199 1_12 U,99 U2 5 6 U1 1 U2 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY 0 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S 0$501-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash 0 AMENDED YR 2025I 2025-00030038 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 -11 DUNDEE AVE El In 03:57 ® ❑ RELATED ®Y 0 N 05 12 2025 ®AM ❑YES ®NO U1 -< _ _ g PRIVATE mo !day!yr ❑PM FLOW CONDITION m FT!MI N E S W PAGE AVE COUNTY PROPERTY ElY ® N DOORING Ely #OF MOTOR El SLOW Cl)❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD ❑ STOPPED U2 --I ® 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 0 FOR DAMAGEDAREA(S) FROnrr TOWED U1 Q Unknown. Unknown.0 BMW 530 2021 00-NONE ©t O i_, DUE TO CRASH ® ❑ O.NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 10 l , 2 FIRE 0 IE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED U2 9 9 SYSTEM IN O ENGAGED O 15-OTHER 9 16.TOP 3 0 _ ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN a 4 `Distraction Value 9 ALGN CITY STATE ZIP IONJ EJCT9 EPTH9 PLATE NO. STATE YEAR FIRST OF 12 7_ �nl-_5 ClOyes.See Sidebar❑ i� U1 1 0 Z EV81756 IL gip' ' E TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED WBA13BJ03MWX11424 Geico ❑Y ®N U2 �r- 5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Graciano.Alan 6194182280 1 rn `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 99 0 ❑ DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMV 0 NCv 0 DV CIRCLE NUMBER(S) U1 yr 12 - C1 o 13-UNDER CARRIAGE 1O.i t, 2 FIRE 0 0 U2 C c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN ENGAGED 15-OTHER 9,16•TOP3 ❑ ❑ SPDR 0 0 Y ❑N 0 UNK VEH. AT CRASH 99-UNKNOWN `Oistraellon Value U1 9 - POINT OF s-.;, 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT TA—d:-6 C•IO e1sYEH See •SidebarO 0 C CO F` ---- co M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O ❑Y ❑N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = BAC HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < RESPNDER❑YD❑N U1 = (UNIT) (SEATI (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0 / / U2 r m Pj / 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 43 4 Public Works. Elgin Traffic Signal 05,12 ,2025 03 58 ®❑pM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 v t 2 1900 HOLM ES RD ELGIN IL 60123 28 25 1 ! ❑PM 0 Construction >F Z3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 -a, ARREST NAME / / 0 PM ' o N 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility 30 SLMT F 2 0 ARREST NAME AM 7 ! r ❑❑PM 0 Unknown work zone type U1 n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y 2 3 0 ❑AM Workers present? ❑ 1524 Silva Jose 201 331-Ziegler r , ❑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 e-----e••--, , ; 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 truckrtrailer -< c ` --I -' r INDICATE NORTH combination):or —I MI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ElI - (example:shuttle or charter bus):or X 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I A O } } } transporting employees In the course of their employment(example:employee X a transporter-usually a van type vehicle or passenger car):or w L L____a____� c.i. / 4. Is used ordesi natedtotrans transport passengers,including C } } } g po fc rs, or the driver, for direct compensation(example:large van used fors specific purpose):or 'O L L____a____� „,„, �I , M _ l. i. iD 5. Is any vehicle used to transport any hazardous material(HAZMAT)thatrequires m if placarding(example:placards will be displayed on the vehicle). ;p / _ CARRIER NAME Z o O a;,�,,, ADDRESS D Not To Scale . CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate 0 Intrastate 0 I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other ; _Y_ __1 - USDOT NO. ILCC NO. m XI Source of above z . Form Number m Xl IDOT PERMIT NO. WIDELOAD'; 0 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_COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Silver u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. _Artier/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U_DUE ETOO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BYlT6 DUE T VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE