HomeMy WebLinkAbout2025-00033739 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
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 AMENDED ® 6 Injury and f or Tow Due To Crash YR 2025512025-00033739 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 '1
270 N GROVE AVE Elgin09:44
® ❑ RELATED ❑Y ®N 05 27 2025 ®AM El YES IX]NO U1 -<
_ _ PRIVATE mo !day/yr ❑PM FLOW CONDITION MCOUNTY PROPERTY ®Y El N DOORING ❑y #OF MOTOR 0 SLOW Cl)
❑ FT/MI NESW Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS O
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0 Ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
0 7 !
Buick Terraza 2005 00-NONE 11 OI_, ODE TO CRASH ® ❑ E
13-UNDER CARRIAGE 1a , 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 m
F 2 SY4 ❑Y ONM❑UNK VEH. O AT CRASH IN 0 is-OTHER
99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s_iL 6 4,.4 COM VEH ❑ E! 1 0
~ ELGIN N I L 60123 B 1 0 FIRST CONTACT 12 7_; _5 *II Yes.See Sidebar Ut
Z EY27623 IL 2025 REAR
TELEPHONE
IL D 5GADV23L85D273211 Allstate El ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire Same 975245720 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Provena St.Joseph ❑Y El 2 ou
0 DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 row 0 i v 0 Dv
yr 12 _ 71
Ti 13-UNDER CARRIAGE 10.i t, FIRE ❑ ❑ U2 C
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 0 ❑ SPDR 0
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value U1 9 -
POINT OF s-.;, 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT TA—d:-5 COM•I sVEH See •Sidebar❑ 0
C
CO
F` ---i co
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O
❑Y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
BAC
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
RESPNDER❑YD❑N U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0
/ / U2 r
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DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 43 3 Gail Borden Library Tree 05,27 /2025 09 44 ®❑pM AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
v 1 2 ❑ 270 N G ROVE AVE ELGIN IL 60120 17 28 ! r ❑PM ❑Construction
Z3 ❑ Igi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2
-a, ARREST NAME Shales.Jamie. L. 11-601-Ax 1504000515 r ! El PM SLMT
o u 1 ❑ MI CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility
o N 0 AM 25
r 2 El ARREST NAME Shales.Jamie. L. 11-709-A 1504000514 ! r PM Unknown work zone type U1
n 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y
1504-Real, Hilario 102 275-Engelke 06 ,24/2025 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 truckrtrailer -<
i- }--__r-_--; } INDICATE NORTH combination):or —I
P1
0 ARROW 2 Is used or designed to transport more than 15 passengers including the driver n
_ } (example:shuttle or charter bus):or
X
3. Is designed to car 15 or fewer passengers and operated a contract carrier O
•
,,, } } } transporting employees In the courses of their employment(example:employee
{ I transporter-usually a van type vehicle or passenger car):orCO
L L.___a____� ', I } } } •4. Is used or designated to transport between 9 and 15passen rs,includingthedriver,
I :.1 for direct compensation(example:large van used for specific purpose):or 0
L L____a____� r� I I r t i i i 5. Is any vehicle used to transport anyhazardous material(HAZMAT) m
placarding(example:placards will be displayed on the vehicle). ;p
—I
CARRIER NAME Z
r I ADDRESS 0
T.
. . . . I [1 rn
Not To scale J n
CITY/STATE/ZIP 0
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
------------ - USDOT NO. ILCC NO. rn
XI
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?
❑ Yes II No ElUnknown A
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
v
TRAILER WIDTH(S) 0-96" 97-102" >102' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U_COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BYITO.
Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U_TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO:
DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE