Loading...
HomeMy WebLinkAbout2025-00035085 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 4 Sheets 01111101111 I0110110011 0 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003846531 u, 1 U2 1 1 1 U115 U2 1 U, 1 U2 U, 1 U2 1 5 9 u, 1 U221 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW ' Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 7 VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ® B Injury and for Tow Due To Crash YR 2025I 2025-00035085 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 71 936 VILLA ST Elgin09:48 ® ❑ RELATED ❑Y ®N 06 01 2025 ❑AM ❑YES ®NO U1 —< _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION MCOUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR 0 SLOW 3 Cl) ❑ FT/MI N E S W Cook HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 -I 0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0 Q83 DRIVER I] PARKED I]DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N O n FOR DAMAGEDAREA(S) FROf tf TOWED U1 Q Ville as.Yvette. D. 0 1 / yr 13-UNDER CARRIAGE ©, 0 FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) OIP�O DISTRACTED 0 0U2 0 m F 9 4 ❑Y ❑N SYSE El UNK VEH. 9 AT CRASH M IN ENGAGED9 99-UUNKNOWN THER 016-T Distraction Value ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF D it S �I COM VEH 0 Ea 1 C) F. FIRST CONTACT 1 7__,,c--_;-06 `ir Yes.See Sidebar U1 0 Z REARRoselle IL 60172 0 1 0 3879712B IL 2026 REAR TELEPHONE IL D 1 FTFW3L81 RKF78458 State Farm ❑Y ®N U2 19 . m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Clinch.Justin. M. 2057087SFP13 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 XI ❑ DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMV 0 Ncv 0 DV yr 10;j 12 . 2 FIRE 0 El U2 1 C Ti 13-UNDER CARRIAGE SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN 9 ENGAGED 9 15-OTHER 911,6•TOP3 ❑ ® SPDR n ❑Y ❑N ®UNK VEH. AT CRASH 99-UNKNOWN `Oistraci n Value U1 0 POINT OF s-.;, 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR � S COM VEH ❑ ® CO F„ FIRST CONTACT 5 7 O6 •If Yes,See Sidebar U13943 IL RE 0 fp M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 1 FTSE3EL5BDB17860 unknown ❑Y 0 N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = CENTRAL MANAGEMENTS unknown BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE:ZIP U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) 0 E/ MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 18 5 06 101 /2025 09 48 ®PM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 � 2 0 28 28 N 1 3 0 CITATIONS ISSUED 0 PENDING + ! ❑PM• El Construction SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5 —a, ARREST NAME / / El PM ' o N 1 ® 11 5 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT 15 t 2 ARREST NAME AM T 1 r ❑❑PM El Unknown work zone type U1 El n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ - ❑AM Workers present? ❑Y 15 1522-Velazquez. Noeli 302 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 .Z-1 ® BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver _ (example:shuttle or charter bus):or X L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier O } } } transporting employees in the course of their employment(example:employee X transporter-usually a van type vehicle or passenger car):or w L L.___a____� 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including N } } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or O L L--_-a-___. - t i I 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example:placards will be displayed on the vehicle). XI —I CARRIER NAME Z �. ADDRESS 0 w Not To Scale I CITY/STATE/ZIP 0 g MOTOR CARR.ID 0 Interstate 0 Intrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other �I. ------1 - USDOT NO. ILCC NO. rn XI Source of above Z . ❑ Yes 0 No 0 Unknown g D Did Carrier Safety Regulations MCS)violation contribute to the crash? A ❑ Yes No ❑ 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'; 0 Yes 0 No 2 TRAILER VIN 1 m co LOCAL USE ONLY TRAILER VIN 2 m 0 TRAILER WIDTH(S) 0-96" 97-102" >102' m TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Gray White u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO. _Other/Police Department . 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