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HomeMy WebLinkAbout2025-00033022 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 011011000 I0fl 00 1100 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XO03631166 u, 1 U21 1 1 1 u, 4 U2 1 u, 1 u2 1 u, 1 u2 1 4 9 u, 1 U221 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S ❑$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 2025-00033022 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn ® ° RELATED ❑Y ®N 05 24 2025 IMAM ❑YES ®NO U1 —< GRAND AVE Elgin03:29 _ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m FT l MI N E S W PRESTON AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR El SLOW 1 (n ❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0 Q83 DRIVER O PARKED O DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 1 C) 0 3 ! yr 13-UNDER CARRIAGE ©,I :: FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 1 r<rl M 2 SY4 ❑Y ®SNE❑UNK VEH. O AT CRASM IN H O 99-UNKNOWN 9 ,6•TOP 3 `Distraction Value ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF & i�S 4 COM VEH 0 Ea 1 O ~ ELGIN IL 60120 0 1 0 FIRST CONTACT 12 7 . _5 *IfYes.SeeSidebar U1 Z CL77787 IL 2025 TELEPHONE IL D SHHFK7H4OMU401204 None ❑Y ❑N U2 I— .5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same None 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER XI Refused ❑Y El 2 0 0 DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMv 0 KCV 0 DV yr 10' 12 c, 2 FIRE ❑ El U2 1 C o 13-UNDER CARRIAGE c 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 NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istrac) n Value U1 3 POINT OF 8 I -4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR S COM VEH D ® CO F,,, FIRST CONTACT 6 O7 ,�=QI 05 •IfYes See Sidebar C CZ18856 IL 2025 0 N M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 2HGFA1 E5XAH537264 Magnum Insurance ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 = Same 12-2435379-01 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < RESPOND❑YElN u1 = Y (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0 O EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2Z u 1 ® 18 1 05,24 l2025 03 29 ®❑PM in a Work Zone? ®N DIRP co 1 Nt PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM u1 Oi 2 ❑ 18 1 28 99 ! 1 ❑PM, ❑Construction * Z 3 ❑ Ii CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM ❑Maintenance U2 o ® 11 1 ARREST NAME Wiley. Napoleon 11-601 S1552000068 ! ! ❑PM SLMT lgi CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME NAM 0 Utility t 2 ❑ ARREST NAME Wiley. Napoleon 3-707 S1552000069 05 r 24 l2025 04 17 j PM El Unknown work zone type U1 25 n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 El El Ahmad Rashad 202 331-Ziegler 06 , 17/2025 01 30 El PM Workers present? ®N U2 25 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 truckrtrailer -< ` ` -' -' r INDICATE NORTH combination):or .Z-1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C (example:shuttle or charter bus):or 0 I 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O N - I. } } transporting employees in the course of their employment(example:employee � transporter-usually a van type vehicle or passenger car):or w P1e n?nvs 4. Is used or designated natedtotrans rtbetween9and15 passengers,including N } } . • for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or O D t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)thatrequires m Not To Scale placarding(example:placards will be displayed on the vehicle). XI CARRIER NAME Z ADDRESS 0 illkil \..-_ w CITY/STATE/ZIP 0 MOTOR CARR.ID 0 Interstate El Intrastate 1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other r ------------ - USDOT NO. ILCC NO. rn Ormrd?Ave ' ' ' X1 Source of above z . xi Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z own tank)? 0 Yes 0 No 0 Unknown T. 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' m TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 ❑ O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Red Black u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. _Redmons/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 ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE