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HomeMy WebLinkAbout2025-00035643 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets II III 11 IIII IIIIII U lUOUU III 111I11OO1 U DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003846105 u, 1 U21 3 4 2 U1 8 U2 1 U, 1 u2 1 U, 1 U2 1 1 12 U1 1 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S 0$501-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash El AMENDED YR 202512025-00035643 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I ® ❑ RELATED ®Y 0 N 06 04 2025 ❑AM ❑YES ®NO U1 -< E HIGHLAND AVE Elgin01:00 _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m FTlMI N E S W DOUGLAS AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 Cn ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLESOT, INVLD ® STOPPED U2 --I lgi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL ❑EDUCE ❑uuv ❑!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C) FRorar TOWED U1 Q ad en.Christian. L. Buick Enclave 2017 00-NONE 1 12 , DUE TO CRASH ® ❑ P NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE © IE 10,I I�. 2 FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 0 m M 2 SYTM IN ENGAGE15-OTHER 4 ❑Y ®SNE❑UNK VEH. 0 AT CRASHD 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF & i�B �i 4 COM VEH 0 ix) 1 0 H 1- PINGREEGROVE IL 60140 0 1 0 FIRST CONTACT 11 T_; __S *IIYes.SeeSidebar U1 ZCA50824 IL 2025 REAR TELEPHONE IL D SGAKVCKDOHJ209001 No insurance ❑Y 0 N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m co 99 9 Reyes.Cynthia No insurance 2 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 X p; DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 r uv 0 KCV 0 DV /1 9 8 2 Honda Pilot 2013 00-NONE 11__) 12 0 DUE TO CRASH 0 [gI 2 , o Yr 13-UNDER CARRIAGE 10 2 FIRE 0 ® U2 C F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X ❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value 7 0 POINT OF s i1 �i COM VEH 0 ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 5 FIRST CONTACT 1 Y _,__5 •IfYes.See SidebarC 1= ELGINZ IL 60123 0 1 0 R525271 IL 2025 I 0 IL D 5FNYF4H28DB020843 Allstate ❑Y ®N RDEF P3 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Same 811362199 BAc $ 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 0 EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 4 06,04 l2025 01 00 ®pm in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 � Si 2 0 20 18 1 r 0 PM El Construction * Z 3 0 Ii CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 ❑AM ❑Maintenance U2 o 1El 11 4 ARREST NAME Padjen.Christian. L. 3-707 752138 ! r ❑PM SLMT MI CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility o N 0 ElAM r 2 El ARREST NAME Padjen.Christian. L. 11-402-A 752139 r r PM Unknown work zone type U1 2 2 3 ❑ OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30 486-Munoz.Jasmine 100 06 /26 r2025 09 00 ❑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 -< c ` --I -' r INDICATE NORTH combination):or .Z-1 1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C e. (example:shuttle or charter bus):or C r 3. Is designed tocarry 15 or fewer passengers and operated a contract carrier O I- I- --I-- --J. J I y } } } transportinggemployees in the course of their employment ployment(example:employee E.4Hi Iand7Ave sr ' ' ' ' transporter-usually a van type vehicle or passenger car):or CO --._ C i. ...I. `I__-) I. } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver, w for direct compensation(example:large van used for specific purpose):or l l l - - - • ' r.) - - - 'OD - } } } t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example:placards will be displayed on the vehicle). ,Zmt . 1 N I m CARRIER NAME II ' ADDRESS O 0 D , C) " CITY/STATE/ZIP n Not To Scale 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. m XI Source of above z : Form Number m Xl IDOT PERMIT NO. WIDELOAD? ❑Yes 0 No 2 TRAILER VIN 1 m to 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 Red Green u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO. _Adieu/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE