HomeMy WebLinkAbout2025-00034590 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II III H IM Mil U lUOUU IIII1*UI11lI1DD
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑sso,-g1,500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 2025I 2025-00034590 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 71
® ❑ RELATED ®Y 0 N 05 30 2025 ❑AM ❑YES ®NO U1
LAWRENCE AVE Elgin08:52
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W N STATE ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 16 co
❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD ® STOPPED U2 --I
lgi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 01 0
FOR DAMAGEDAREA(S) FROM TOWED U1
NAME(LAST,FIRST,M) Moore. Essie.S. mol /
/1 9 5 4 Ford Escape 2017 00-NONE 11_' Qi�, OUETOCRASH ❑ VI E
13-UNDER CARRIAGE 10 i : 2 FIRE 0 NI
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® 0 U2 m
F 10 3 Y SYSTEM IN ENGAGED 15-OTHER 9 t6.TOP 3 9 ALGN =
❑ ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6_iL 6 4 COM VEH 0 j$J 2 O
I .
Hanover Park I L 60133 0 1 0 FIRST CONTACT 12 7_: _5 *II Yes.See&debar U1
Z EP45198 IL 2025 REAR
TELEPHONE
IL D 1 FMCUOF73HUD24517 Unknown ❑Y ❑N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same Unknown 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
''F, D Y°®N 0
❑ DRIVER 0 PARKED 0 DRIVERLESS FED 0 PEON. 0 EWES 0 NMv 0 KCv 0 DV
!2 0 yr 1 Other Other 00-NONE 1("j t2'-_1 DUE TO CRASH ❑ ❑ 98 xi
0mo 13-UNDER CARRIAGE 10 2 FIRE 0 0 U2 C
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❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `OistraglonValue 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 11:--4 COM VEH 0 0 U1 CO
FIRST CONTACT 15 7� � .5 •IfYes.See Sidebar C
m ELGIN IL 60120 B
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IL N/a ❑Y ❑N RDEF X1
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Elgin Fire 1 51 2 Moore. Essie.S. N/a BAC
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HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOBI (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(A.DDRESS)1(TELEPHONE) (EMS) (HOSPITAL)
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
u 1 ® 12 1 05,30 /2025 08 52 ®AM in a Work Zone? ®N DIRP co
I r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
2 0 25 2 05,30 /2025 08 53 PM
® • ❑Construction *
Z 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
-a, ARREST NAME 05/30/2025 08 57 ®pM
® 12 1 0 CITATIONS ISSUED ❑PENDING UtilitySLMT
o N 1 SECTION CITATION NO. ROAD CLEARANCE TIME 0
r 2 0 ARREST NAME 05/30 /2025 09 11 ®PM El Unknown work zone type U1 35
x AM
T
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y
2 2 3 0 - ❑AM Workers present? ❑
1525-NavE.Oscar 601 / / ❑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••--, , ; 0 A CMV is defined as any motor vehicle used to transport passengers or property and:
1. as a weight rating more than 10,000 pounds(example:truck or truck trailer T.
-<
c -----------I Not To Scale f - combination):or —I
INDICATE NORTH p1
\ 1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
(example:shuttle or charter bus):or n
, r r X
3. Is desgned to car 15 or fewer ssen ers and o rated a contract carrier O
- ------I----; - } } } transporting employees In the courses of their employment(example:employee
1\\\
, , transporter-usually a van type vehicle or passenger car):or C
L L.___a____� o I. 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including to
} } for direct com nation exam I lar a van used for s �cifice ur o ):or the driver,
Pe ( P 9 Pe p pose):or O
L i t i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D
' placarding(example:placards will be displayed on the vehicle). m
0
CARRIER NAME Z
-- L aWrentrolAY6 1\ \ \
1 ADDRESS T.
CITY/STATE/ZIP 0
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\
- i. i. i. i. MOTOR CARR.ID 0 Interstate ElIntrastate
I I T I; \ ❑ Not in Comm./Govt. Not in Comm./Other
_...Y._._. - USDOT NO. ILCC NO. rn
XI
Source of above 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' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Silver
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 9 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE