HomeMy WebLinkAbout2025-00035544 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Of 2 Sheets 01111101111 0110110000111 fll IOU
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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 El$501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
El AMENDED
YR 202512025-00035544 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
N MELROSE AVE EIIn
® ❑ RELATED ®Y 0 N 06 03 2025 DAM ❑YES I NO U1
10:34
g PRIVATE mo !day!yr ®PM FLOW CONDITION m
FT!MI N E S W W CH ICAGO ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR El SLOW 1 cn
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!Cy 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
0 7 !
yr 13-UNDER CARRIAGE 10l �. 2 FIRE 0 N
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
F 2 SYTM IN ENGAGETHER
5 ❑Y NSNE❑UNK VEH. O AT CRASH O 99-U15-UNKNOWN 9 76-TOP® ,Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 ;i� 6 �I COM VEH 0 j$J 1 n
~ Bridgeport IL 0 1 0 EF68176 IL 2025 FIRST CONTACT 3 7 :REAR
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TELEPHONE
IL D 1 G 1 AK58F387343708 Progressive ❑v Il N U2 I—
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 964501360 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Refused El ® N 2 0
p; DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 Ntry 0 NCv 0 DV
yr Honda Civic 2011 00-NONE 0 Qj O DUETOCRASH rg ❑ 2 �7
o 13-UNDER CARRIAGE 10 I I.. 2 FIRE ❑ N U2 C
II
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF .i�.._.4 COM VEH ❑ N U1 CO
FIRST CONTACT 10 7 _, .6 •It Yes.See Sidebar C
E LG I N I L 60123 0 1 0 CH 83739 I L 2025 RFJ 0 fn
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IL D 2HG FA1F54BH535462 American Alliance ❑Y N N RDEF Xl
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same ILAA-1038291-00 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)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
u 1 ® 11 1 61 ,12 !25 10 34 ®AM in a Work Zone? NCI N DIRP co
1 t PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 5 n
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0 2 ❑ 2 23 , , ❑PM ❑Construction
3
R 3 ❑ $I CITATIONS ISSUED PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM ❑Maintenance U2
o1 ® 11 1 ARREST NAME Campos. Milagros. D. 11-601 457-658 ! ! ❑PM SLMT
o N
❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' ❑Utility
30
t 2 ❑ ARREST NAME AM
T 1 r ❑❑PM El Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ ❑AM Workers present? ❑Y 30
457-Fearol. Megan 601 331-Ziegler , , ❑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_-__; I combination):or
INDICATE NORTH
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
` i w.rcniauwrar. - i. e. r r (example:shuttle or charter bus):or 0
. . 3. Is designed to carry15 or fewer passengers and operated a contract carrier O
I- I- --I--.-.� I c I..cJJ - . } } . transportinggemployees in the course of their employment
ployment(example:employee 73
I o transporter-usually a van type vehicle or passenger car):or w
` `""'.L----i e.v►wrorozAve N.aeureeevAve - } } 1 •4. Is used or designated to transport between 9 and 15 passengers,including the driver,
- - u,.:.;) for direct compensation(example:large van used fors specific purose):or 0
r•- - - - •I
__ Unlit - l. I 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
T . . . . placarding(example:placards will be displayed on the vehicle).
I _ CARRIER NAME Z
ADDRESS 'Z
T.
r
I O
r.N- CITY/STATE/ZIP
_ r
Not To Scale l MOTOR CARR.ID 0 Interstate 0 Intrastate O
l I . l ❑ Not in Comm./Govt. ❑ Not in Comm./Other
0
; _Y_ _-1 USDOT NO. ILCC NO. m
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
71
IDOT PERMIT NO. WIDELOAD'; ❑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' -n
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Blue Blue
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO.
Arties/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Arties/Impound.Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE