HomeMy WebLinkAbout2025-00027354 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets _ 01111101111 011011000 l 11
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003&19120
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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$1,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 2025I 2025-00027354 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
1050 WING ST Elgin08:27
® ❑ RELATED ❑Y ®N 04 30 2025 DAM ❑YES ®NO U1 —<
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ FT/MI NESW Kane HIT ®Y ❑ N WITH VEHICLES INVLD ❑ STOPPED U2 --I
El AT RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES p NW p!CV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 02 n
FOR DAMAGEDAREA(S) FRONr TOWED U1 Q
Unknown. Unknown ! , Unknown Unknown 2013 00-NONE „ 12 , DUE TOCRASH ❑ EN
NAME{LAST,FIRST.M) mo yr 13-UNDER CARRIAGE 1 IE
01 ! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 02 rn
3 4 SYSTEM IN O ENGAGED 0 15-OTHER 9 16.TOP 3 _
❑Y ®N ❑UNK VEH. AT CRASH ®-UNKNOWN `Distraction Valuc 9 ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S_iL s 4 COM VEH 0 j$J 1 0
I— 0 1 0 FIRST CONTACT 99 7_• __5 *If Yes.See Sidebar U1
ZFC71983 IL 2026 E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1)
5N1AR2MM3DC606539 unknown ❑Y ❑N U2 I—
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST.FIRST,M) POLICY NUMBER RSUR m
99 9 Same unknown 2 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
r RESPONDER 0
5, 0 DRIVER N. PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 NMv 0 KCv 0 DV
yr Nissan Rogue 2020 00-NONE 10' t2 (,-2 FIRE TO CRASH ® U2 1 C o 13-UNDER CARRIAGEEl Ti
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP3 ❑ ® SPDR n
❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN `Oistrac Dn value Q U1 0
POINT OF 8 ) -4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR S COM VEH ❑ ® CO
F,,, FIRST CONTACT 6 O7 ,�=QI 05 •If Yes.See Sidebar C
DK75034 IL 2025 i:EaR0 fp
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
KNMAT2MV7LP521189 Geico ❑Y ®N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Chittavong.Silivanh 4474-34-21-53 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE;ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME){{ADDRESS))(TELEPHONE) (EMS) (HOSPITAL)
W 03 /
0 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 04 130 /2025 08 27 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 0 20 99
N 3 0 CITATIONS ISSUED 0 PENDING + ! 0 PM• El Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5
z
—a, ARREST NAME / / El PM '
o N 1 ® 11 5 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT
10
r 2 0 ARREST NAME AM
7 , , ❑❑PM El Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 1506-Nunez. Maria 501 391-Jacobucci , , ❑❑PM Workers present? ®N U2 10
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 -<
` ` -' -' r INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} 111r0`71MNG?R RK48T _ } (example:shuttle or charter bus):or 0
0 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier O
�' I. . . transporting employees in the course of their employment(example:employee X
•Ifl
[! 1j
transporter-usually a van type vehicle or passenger car):or w
"'I Not To Scale _ 4. Is used or designated to transport between 9 and 15 passengers,including the driver. y
I. 1. for direct compensation(example:large van used for specific purpose):or Il ) o
I I --
< <____a____. uMr+ _ t i. i. t -U 5. Is any vehicle used to transport any hazardous material(HAZMAT)thatrequires m
placarding(example:placards will be displayed on the vehicle). ;p
—1
CARRIER NAME Z
ADDRESS 0
w
C)
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
‘I. -- - - USDOT NO. ILCC NO. m
XI
Source of above z
.
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 Black
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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE