HomeMy WebLinkAbout2025-00031565 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
I011011000 01
III II III IIIIII
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003626531
u, 1 U21 2 1 1 U, 5 U2 1 U, 1 1_12 1 U1 1 U2 1 1 10 U1 3 U2 1 *P 0119*
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 ❑$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500
El NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00031565 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 m
® ❑ RELATED PRIVATE ❑Y ®N 05 18 2025 ❑AM ❑YES ®NO U1
N STATE ST Elgin mo /day/yr 03:46 ®PM FLOW CONDITION M
_
®15co,MI O E S W Schiller St COUNTY PROPERTY ❑Y ® N DOORING El #OF MOTOR 0 SLOW 1 (n
Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
gi DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0
0 2 /
yr
13-UNDER CARRIAGE 10 i 12 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 4 rn
F 2 4 SYTM❑Y ®SNEDUNK VEH. 0 ATCRASHD 0 15-99-UUNKNOWN THER9 16•TOP 3 `Distraction Value 9 ALGN X.
V. CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 7_it S COM VEH 0 0 1_5 *If Yes.See Sidebar Ut 4 0
F. FIRST CONTACT 00 ,_
Z Streamwood IL 60107 0 1 0 CJ95332 IL 2025 Is
TELEPHONE
IL D 1 G N LRFED6AJ208694 All State ❑Y Il N U2 I—
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 974503419 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 c
g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 iiuv 0
/2 0 0 1 Hyundai Elantra 2008 00-NONE O I t2 c 2 FIRE O CRASH 0 ® U2 2 C
Ti 13-UNDER CARRIAGE
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 X
❑Y Ni N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistrac on Value 9 0
i1i N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF FIRST CONTACT OO 8 7 B -4 COM VEH
.5 •
— Elgin IL 60120 0 1 0 ES64922 IL 2026 I If Yes.See Sidebar❑ ® U1 CO
0 C
IL D KMHDU46D68U526642 Ameican Alliancce ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
99 9 Same I LAA-1069444-00 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)
1 6 12 / 2 3 0 1 0
m
/ / #OCCS D
71
/ / UI 2 D
/ / 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 1 51 ,81 /025 03 46 ®AM 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
o"
2 ❑ 20 06 / / 0 PM ❑Construction *
R 3 ❑ $I CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
-a, ARREST NAME Williams.Sebrina.S. 11-709-A 1550-000070 / / ❑PM SLMT
oN 1 3 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility
r 2 ® 31 3 ARREST NAME AM
7 , / PM ❑Unknown work zone type 35
U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT GATE TIME ❑AM Workers present? ❑Y 35
1550-Camacho.Oscar 501 391-Jacobucci 61 , 01 ,025 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
} IN - i. e. r ,. (example:shuttle or charter bus):or 0
1 i I El
"'" 3. Is designed to carry15 or fewer passengers and operated a contract carrier O
- ------ -•-• I 3 } } } transportingemployees In the course of their employment
type passenger car):(example:r employee
transporter-usual) a van vehicle or
L I4. Is used or designated to transport between 9 and 15 passengers,including N
-- -- - I I } g Po passen rs,includi the driver,
for direct compensation(example:large van used for specific purpose):or O
L _ 5. Is any vehicle used to transport an hazardous material(HAZMAT)that requires M
amnaxs� placartling(example:placards will be displayed on the vehicle).
- - — —
CARRIER NAME Z
ADDRESS
N.? n
Not To Soaks CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
-----------1 - USDOT NO. ILCC NO. rn
XI
Source of above z
. 0 Yes i0 No ❑ Unknown A
C
Was a driver/vehicle Examination Report Form completed? r
HAZMAT ❑Yes 0 No ❑Unknown Out of Service ❑Yes ❑No :
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
v
TRAILER WIDTH(S) 0-96" 97-102" >102' T
TRAILER 1 0 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Gray Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 0 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE