HomeMy WebLinkAbout2025-00034623 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 4 Sheets 01111101111 I011011000 I0fl
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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 16
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 202512025-00034623 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
REINKING RD Elgin11:22
® ❑ RELATED ®Y 0 N 05 30 2025 ❑AM ❑YES ®NO U1 -<
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W RT20 COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR ❑SLOW 2 1JA
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑NW ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N O 0
FOR DAMAGEDAREA(S) FROM T TOWED U1 Q
NAME(LAST,FIRST,M) Kramer.Addison. N. 0 mo1 / /2 0 0 8 Acura TL 2019 00-NONE „ Oi_, ODE TO CRASH ® ❑
13-UNDER CARRIAGE 16 i , 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ U2 0
)Si I'll
F 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 76-TOP 3 _
❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF il_6 I, 4 COM VEH 0 )g) 4 O
f. FIRST CONTACT 11 7_:—__;__5 *II Yes.See Sidebar U1
Z Saint Charles IL 60175 B 1 0 CV41231 IL 2025 REAR
TELEPHONE
IL D 19U U B3F69KA001204 State Farm ❑Y ®N U2 m
B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire Kramer. Ryan 2446741 SFP13 1
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER r
D
RESPONDER
Refused ❑Y ® N 2 XI
g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑row 0 NCV ❑DV
!1 9 6 4 Ford F150 2013 00-NONE i1_"j Q�,-_, DUE TO CRASH rg 2 x
o 13-UNDER CARRIAGE 10) 12 FIRE ❑ ® U2 C
II
M 2 4 SYSTEM IN ENGAGED 15-OTHER 9,16-TOP 3 X
❑Y 0 N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 0 U1
POINT OF 6 i1�I 4 COM VEH ❑ ® W
N
CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 12 7 B -5 *(ryes,See Sidebar
n BELVIDERE IL 61008 0 1 0 3332584B IL 2026 iiEaR
Z
IL D 1 FTFW1 EF9DFA51544 State Farm ❑Y J N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 3590668SFP13 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
1 3 06 /
' D
/ / 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 El 11 4 05,30 /2025 11 22 ®pm 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
0 2 ❑ 23 28 , , ❑PM ❑Construction
R 3 ❑ )yj CITATIONS ISSUED El PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM ❑Maintenance U2
o1 ® 11 4 ARREST NAME Kramer.Addison. N. 11-1204-B 298001243 ! / ❑PM SLMT
o N
•
❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility
30
r 2 ARREST NAME AM
1 / ❑❑PM ❑Unknown work zone type U1
El
T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 El ❑AM Workers present? ❑Y 30
298-Lopez, Mirko 901 - r / ❑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 -<
i- }__-_r_-_-; INDICATE NORTH combination):or
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BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} - } (example:shuttle or charter bus):or X
. 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
' I. } } transporting employees In the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or CO
4. Is used or designated to transport between 9 and 15 passengers,including rCjt
} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or o
II 1:1
L L____a____. } } } t 5. Is any vehicle used to transport an hazardous material(HAZMAT)thatrequires
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-, a placarding(example:placards will be displayed on the vehicle). �1
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e�rK+ a i Not To Scale J CARRIER NAME Z
' ,';1 1 _ __ ADDRESS0
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CITY/STATE/ZIPg
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MOTOR CARR.ID 0 Interstate ❑ Intrastate
r ❑ Not in Comm./Govt. ❑ Not in Comm./Other 0
--- --1 - USDOT NO. ILCC NO. C
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Source of above z
. Form Number
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IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
a
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
Gray Blue
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 DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE