HomeMy WebLinkAbout2025-00030906 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 101101100001011100100
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV XO03823913
u, 1 U21 3 4 1 U1 2 U2 1 U1 1 U2 1 U1 1 U2 1 1 10 U, 3 U2 1 *P 0119
INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) El B Injury and f or Tow Due To Crash
El AMENDED
YR 2025I 2025-00030906 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED ®Y 0 N 05 15 2025 DAM ❑YES ®NO U1 -<
BIG TIMBER RD Elgin06:38
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W N LYLE AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ Kane HIT&RUN ❑V ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 --I
El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
C)
FOR DAMAGEDAREA(S) FRONT TOWED U1 Q
NAME(LAST,FIRST,M) Nino.Victoria.A. mo 1 0 / /1 9 9 2 Chevrolet Equinox 2022 00-NONE VI E
13-UNDER CARRIAGE „_' QI�:/7T DUE TO CRASH ❑
) FIRE 0 NI
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED 0 0 U2 0 m
F 2 4 ❑Y ®SNEM Dis-OTHER
UNK VEH. O AT CRASHIND O 99-UNKNOWN 9 16•TOP 3 `Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 :i1 6 �i,4 COM VEH 0 j$J 1 0
~ ELGIN I N I L 60124 B 1 0 FIRST CONTACT 1 7_. __5 *II Yes.See Sidebar U1
Z DW79106 I L 2026 iivui
TELEPHONE
IL D 3GNAXWEV9NS240744 Falcon Insurance Company ❑Y Igl N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 0100138040-1 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER XI
Refused El El 2 c
g DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑row 0 NCv ❑Dv
!2 O O O Nissan Altima 2009 00-NONE „ " Oj-_, DUE TO CRASH rg ❑ 2 x
0 Yr 13-UNDER CARRIAGE 1; FIRE 0 El U2 C
c
M 2 5SYSTEM IN 0 ENGAGED 0 15-OTHER O9 16-TOP 3 X
0 Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN *Oistracl on Value 0
POINT OF s I 4 COM VEH ❑ ® Ut W
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 5 1: C
FIRST CONTACT 11 7 �. ,�_5 •Iryes.See Sidebar
PINGREE GROVEZ IL 60140 B 1 0 EH14737 IL 2025 I 0 C
IL D 1 N4AL21 E09N427587 Allstate ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire Same 53-435896-00 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER
u1 =
(UNIT) (SEAT) 0)0BI (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 4 05,15 ,2025 06 38 0 AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
v 2 2 28 05,15 ,2025 06 40 ®PM ❑Construction >F
1
R 3 0ixi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ELMS ARRIVED TIME 7
z J ❑AM ❑Maintenance U2
o ® 11 4 ARREST NAME Nino.Victoria.A. 11-801 1552000056 05,15,2025 06 52 Igi pM' 0Utility SLMT
l$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM
t 2 0 ARREST NAME Surprise.Jacob. M. 3-708 1552000055 05,15 ,2025 07 30 0 PM 0 Unknown work zone type U1 45
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? 0 Y 45
1552-Thompson.Ahmad Rashad 502 06 , 17,2025 01 30 0 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
i- }-- --I-- --' I ~ r INDICATE NORTH 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer
combination):or -<
I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ } (example:shuttle or charter bus):or
�'Bip?Timbaf7Rd x
< <-----;-___i - } } } transportinggemployees lloo aeeslin the course of 5 or fewer passengers
er employment example:employee
a contract ner
J it .. - CO
C
-- -- - } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver. N
04 Unit 1 for direct compensation(example:large van used for specific purpose):or o
L i.____a____. _ .. _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
u
placarding(example:placards will be displayed on the vehicle). XI
-
- -- -1
CARRIER NAME Z
ire __ ADDRESS D
B ..' I w
V ~ 0
Not To scale 1
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate 0 Intrastate
l I r l ❑ Not in Comm./Govt. 0 Not in Comm./Other
; _Y_ __ - USDOT NO. ILCC NO. m
N?Lyle?Ave X1
Source of above z
. If Yes,Name on placard 0
4 digit UN NO. 1 digit Hazard class No. Xl
Xl
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z
own tank)? 0 Yes 0 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 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
White Gray
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 2 TOWED BY/TO.
SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE