HomeMy WebLinkAbout2025-00036355 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X4038:45906
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500
El NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and for Tow Due To Crash YR 2025I 2025-00036355 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1
® ❑ RELATED ❑Y ®N 06 07 2025 ❑AM ❑YES ®NO U1 -<
VILLA ST Elgin02:12
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
�30 !MI N E SSouth Liberty St COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
I� ® ® '`� Kane HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
0 2 /
yr 13-UNDER CARRIAGE ! FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) IE
10 O DISTRACTED 0 0 U2 2 m
M 2 SY4 ❑Y ONM❑UNK VEH. 0 AT CRASH IN 0 99-UNKNOWN 9 76•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6_iL 6 i COM VEH 0 j$J 1 0
~ ELGIN I L 60120 0 1 0 FIRST CONTACT 1 7_; __5 *Il ves.See Sidebar Ut
Z EG56292 IL 2025 REAR
TELEPHONE
IL D 0 JM1 BK32F871707325 Kemper ❑Y ®N U2 m
B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
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99 9 Same 12RA000022464 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER en
Refused 0 Y El 2 0
m g DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 r uv 0 NOV 0 Dv CIRCLE NUMBER(S) U1
9 8 9 Toyota Camry 2013 00-NONE ,i_` 12 "_, DUE TO CRASH ❑ (� 2
0 13-UNDER CARRIAGE o 1 l 2 FIRE 0 ® U2 C
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F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 016•TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value 9 0
H CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR PFIRST CONTACT 1 O ONT OF 1 6 L`_5 CIO es See SEH idebar❑ ® utCO
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ELGIN IL 60120 0 1 0 A404605 IL 2025 I 0 Si)
IL C 7 4T1 BF1 FK3DU647444 All State ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 932946619 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)1(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 61 ,J2 /25 02 12 ®PM AM in a Work Zone? ®N DIRP D
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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 C)
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2 0 20 18 1 / 0 PM ❑Construction *
R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
-a ARREST NAME Guzman. Emilio.A. 11-709-A 1504- / 1 ❑❑AM ❑Maintenance U2
1 ® 1 1 1 ❑CITATIONS ISSUED PENDING UtilitySLMT
•
,
o N SECTION CITATION NO. ROAD CLEARANCE TIME El
t 2 0 ARREST NAME 61 112 125 12 45 ®PM ElUnknown work zone type U1 30
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1540-Allah. Muhammad 401 71 112 ,25 01 30 ElPM ®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
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ } (example:shuttle or charter bus):or
, 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier O
I- <.__-A-.--� L _ . } } . transporting employees In the course of their employment(example:employee X
...I.
IMc5 Car, 1 1 transporter sed or d usually designated totransport betweeicle or n 9 and 15r) ssen rs,including the dryer, C
- _ A I• F 9 passengers,_� _® _� � for direct compensation(example:large van used for specific purpose):or O
I < < 1 L 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
a I placarding(example:placards will be displayed on the vehicle). 'D
m
N XI
Not To Scale ' CARRIER NAME Z
- .. ADDRESS 0
l C
CITY/STATE/ZIP 0
0
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
; _Y_ _-1 - USDOT NO. ILCC NO. m
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
to
LOCAL USE ONLY TRAILER VIN 2 m
0
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
Black Blue
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE