HomeMy WebLinkAbout2025-00030619 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 11111111 IIIIII )III 1110I III II
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El5501-51.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 202512025-00030619 VENT
ADDRESS NO. HIGHWAY or STREET NAME ® ❑CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 mRT20 RELATED ' V 0 N 05 14 2025 03_21 DAM ❑YES El NO U1 —<
Elgin PRIVATE mo /day/yr ®PM FLOW CONDITION IT1
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FT N E S W SHANNON PKWY COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 5 Cl)
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ® STOPPED U2 --I
El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUES 0 NOV 0 ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
FOR DAMAGED AREA(S) FRO T TOWED U1 Q
NAME(LAST,FIRST,M) g mo
/1 9 9 9 Ford Ranger 1999 00-NONE „. 0 DUE TO CRASH ® ❑ E
Q
13-UNDER CARRIAGE l0 i : 2 FIRE ❑
2 rn
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ]$I U2
M 2 8 SY❑Y ®SNEM DUNK VEH. 0 AT CRASH IN 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s,_iL s I, 4 COM VEH 0 0 1 C)
F. FIRST CONTACT 1 7 ;—_(__5 *ItYes.See Sidebar U1
Z Carpentersville IL 60110 0 1 0 3532056B IL 2025
TELEPHONE
IL D 1 FTYR1 OCXXUA03788 Progressive ❑v ®N U2 Ill . m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR --1
Same 996854395 1 17`6 HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 XI
Eg DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED 0 PEDAL 0 EWES 0 iiuv 0 NCV ❑ CIRCLE NUMBER(S) U1
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'1 9 6 7 Chevrolet 4500 2021 00-NONE O, Qj-_, DUETO CRASH rg ❑ 7 x
0 13-UNDERCARRIAGE 10i Ic 2 FIRE ❑ ® U2 C
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F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X
a ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s .i�..__4 COM VEH ® ❑ U1 CO
F„ FIRST CONTACT 11 7 -5 •If Yes.See Sidebar C
ELGIN IL 60124 0 1 0 107826SB IL 2025 I 0Si)
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IL B 7 1 HA6G U B7OM N007722 Risk Program Administrati ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
School District 301 PK1010724 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
u1 =
(UNIT) (SEAT) (DM (SEXI {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)!(TELEPHONE! (EMS) (HOSPITAL)
2 6 11 /
LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y
N 1 ® 11 4 05,14 /2025 03 21 ®pm in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
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2 0 06 99 / / ❑PM ❑Construction
Z 3 ❑ Igi CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM El Maintenance U2
o ® 11 4 ARREST NAME Cruz Ramirez.Angel.A. 11-801 S155200054 / / El Pm SLMT
o N
u ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑El AM Utility
t 2 El ARREST NAME 05/14 /2025 04 05 ®PM 0 Unknown work zone type U1 5O
2 2 3 El OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 0 Am Workers present? ❑y 50
1552-Thompson.Ahmad Rashad 901 06 / 17/2025 01 30 ®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 -<
` ` --I -' r INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
T - (example:shuttle or charter bus):or C
I I Rcute t20 i i i T,
j 3. Is designed tocarry 15 or fewer passengers and operated a contract carrier O
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es pa g pe
3 } } } transporting employees In the course of their employment(example:employee X
? transporter-usually a van type vehicle or passenger car):or CO
"mart.' C
I. -----}----, } } •4. Is used or designated to transport between 9 and 15 assen p s including the driver. fn
for direct compensation(example:large van used fors cific pur e):or
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< < } } t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
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a placarding(example:placards will be isplayed on the vehicle).
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3
CARRIER NAME Z
h _ ADDRESS O
T.CITY/STATE/ZIP I n
g
MOTOR CARR.ID 0 Interstate 0 Intrastate
Not To Scale o
I I T I 0 Not in Comm./Govt. 0 Not in Comm./Other 0
---- - --' ShennonW - i. NO. ILCC NO. m
q, USDOT
Source of above z
. xi
• m
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z
own tank)? 0 Yes ® No 0 Unknown
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes 0 No 0 Unknown g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash? A
❑ Yes II El 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'; ❑Yes ®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
White Yellow
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