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HomeMy WebLinkAbout2025-00035425 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II 1 HH 1111 II 11111111 IUUUU I I I U UIUUUU DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X0032421 58* u, 1 U2 1 1 1 U, 2 U2 U1 1 U2 U199 U2 1 1 U1 1 U2 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 7 VEHICLE/PROPERTY El OVER$1,500 El NOT ON SCENE(DESK REPORT) El AMENDED ® 6 Injury and for Tow Due To Crash YR 202512025-00035425 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n 729 S MCLEAN BLVD Elgin 01:05 ® ❑ RELATED ❑Y ®N 06 03 2025 ❑AM ❑YES ®No u1 -< _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR ®SLOW Cl) ❑ FT/MI NESW Kane HIT&RUN ❑Y ® 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 ❑ 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 0 0 1 2 / yr Kia Motors Cokorte 2014 -NONE ©, 12 , DUE TO CRASH ❑ VI 13-UNDER CARRIAGE 10 1 2 FIRE 0IE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ga U2 0 rn F 2 SY 15-OTHER 4 ❑Y ®SNE❑UNK VEH. 0 AT CRASM IN H 0 99-UNKNOWN 9 16•TOP 3 `Distraction Value ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�s 1i COM VEH 0 Ea 1 0 F. ELGIN I L 60123 0 1 FIRST CONTACT 11 7_: __5 *II sees.See Sidebar U1 Z KTR316 IL 2025 REAR TELEPHONE IL D KNAFX4A68E5143415 State Farm ❑Y ®N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m co Same 1981484 sfp 13 1 1— "6 HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ❑ N 2 0 0 DRIVER ❑ PARKED 0 DRIVERLESS El FED 0 PEO/L 0 EWES 0 row yr 12 ,_ X1 o 13-UNDER CARRIAGE 10.i 2 FIRE ❑ ® U2 C c F 1 Y SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 ❑ ❑ ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 0 i1 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF FIRST CONTACT 15 8 I 4 COM VEH ❑ ® Y1-j=.5 •If U1 CO Yes.See Sidebar C H Algonquin IL 60102 B 1 0 N 0 Y ❑N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X Elgin Fire 1 64 9 BAC E HOSPITAL(TAKEN TO) INCIDENT RESPONDER IF'Y' OWNER STREET,CITY STATE,ZIP 996 ARefused ❑Y ❑N U1 = (UNIT) (SEAT) (DOBi (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)+(TELEPHONE) (EMS) (HOSPITAL) W 06 / 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 12 1 06,03 /2025 01 05 ®AM 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 C) Eri 2 0 17 99 ! 1 ❑PM. ❑Construction * Z3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 -a ARREST NAME / / ❑PM ' o N1 ® 11 5 • 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility SLMT , 99 t 2 ARREST NAME AM 7 1 1 ❑❑PM 0 Unknown work zone type U1 El OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ 327-Hromadka.Scott 701 360-Yucaitis , / ❑❑PM Workers present? ®N U2 99 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 —I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver n - } (example:shuttle or charter bus):or X designed Is 15 or fewer he and operated by a c [carner O I- L. _A.._.� N= } } } } transporting employees in thecoursee ottiremptoyment(example:employee X transporter-usually a van type vehicle or passenger car):or w L L.___a.._..I 4. Is used ordesi natedtotrans rtbetween9and 15 passengers,including C } } for direct com nation exam I lar a van used for s �cifice ur o ):or the driver, l Pe ( P 9 Pe P Pose):or O L L__ _a..... ` 1 1 - t i. i 5. Is any vehicle used to transport any hazardous material(HAZMAT)thatrequires m placarding(example:placards will be displayed on the vehicle). ;p -I CARRIER NAME Z ADDRESS 0 T. L. Not To Scale I w CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate 0 Intrastate l I r l ❑ Not in Comm./Govt. 0 Not in Comm./Other ----'Y----1 - USDOT NO. ILCC NO. rn XI Source of above Z . Were HAZMAT placards on vehicle? 0 Yes 0 No = If Yes,Name on placard O 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? 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 v TRAILER WIDTH(S) 0-96" 97-102" >102' T TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Blue 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: TOWED BY/T6 DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE