HomeMy WebLinkAbout2025-00031346 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003626559'
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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 El$501-$1.500 ®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 2025I 2025-00031346 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 �I
ASCOT DR Elgin 03:21
® ❑ RELATED ®Y 0 N 05 17 2025 DAM ❑YES ®NO U1 —<
_ _ g PRIVATE mo !day!yr ®PM FLOW CONDITION MIFT!MI N E S W BOWES RD COUNTY PROPERTY ❑Y 21N DOORING Ely #OF MOTOR 0 SLOW 3 Cl)
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑NIAV ❑NV., ❑ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
FOR DAMAGEDAREA(S) FROPtf TOWED U1 Q
Bennett. Richard.T. 0 7 /
yr 13-UNDER CARRIAGE I FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 2 DISTRACTED 0 0U2 4 <<Tl
M 2 4 SYTM❑Y ®SNE❑UNK VEH. 0 AT CRASH 0 15-99-UNKNOWN THER9 76•TOP 3 *Distraction Value ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, ii_6 1, 4 COM VEH 0 E! 1 0
ELGIN I L 60123 0 1 0 FIRST CONTACT 11 7_: __5 *rives.See Sidebar U1
Z RTB-TS IL 2025 ' E
TELEPHONE
IL D 0 1 FT8W2BT6REE04747 StateFarm ❑v Il N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 2968735SFP13 1 I—
ra HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y ® N 2 XI
m g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑NIAV ❑Ncv ❑Dv
!1 9 8 4 Honda Odyssey 2011 00-NONE „ 12 _, DUE TO CRASH rg ❑ 2 x
o - 13-UNDER CARRIAGE FIRE 0 ® U2
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 016-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN )I *0istractonValue 0
H CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR PFIRST CONTACT 1 NT OF O 0 � 5 CIOMs gee SidebarH ® U1CO
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ELGIN Z IL 60123 0 1 0 BN26547 IL 2025 I 0 Si)
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IL D 0 SFNRL5H63BB070892 Clear Cover Insurance ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
99 9 Same I L228982 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
2 3 1 2 / F 2 3 0 1 0
m
/ / #OCCS D
71
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/ / 2 0
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 4 05,17 l2025 03 21 ®pm in a Work Zone? ®N DIRP co
1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 3 C)
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2 0 2 99 , , 0 PM• ❑Construction
R 3 0 $I CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM 0 Maintenance U2
o1 ® 11 4 ARREST NAME Bennett. Richard.T. 11-901-A 1528-000265 , ! El PM SLMT
o N
❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' El Utility
El AM
t 2 El ARREST NAME 05 r 17 ,2025 03 25 ®PM El Unknown work zone type U1 45
2 2 3 ID OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 45
1528-Rivera. Kevin 701 391-Jacobucci 06 ,23,2025 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 -<
` ` -' -' r INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
X - } (example:shuttle or charter bus):or 0
L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
} } } transporting employees In the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or CO
L •:. .}----. Q - •} } } 4. Is used or designated to transport between 9 and 15 passengers,including the driver. N
for direct compensation(example:large van used for specific purpose):or O
i. i ._ 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires a J placarding(example:placards will be displayed on the vehicle). ,Zmt
Z
0 CARRIER NAME Z
UMW e~7F1.2 _ ADDRESS 0
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Not To Scale CITY/STATE/ZIP 0
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MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other
-"-------1 - USDOT NO. ILCC NO. m
XI
Source of above z
. MCS 0 Yes 0 No 0 Unknown Out of Service 0 Yes ❑No Z
Form Number 0
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Xl
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
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LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 0 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
White Silver
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 DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® Other/Unknown VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE