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HomeMy WebLinkAbout2025-00037666 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100011111 ill 1111111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X463653909 u, 9 U21 2 4 1 U,99 U2 1 u,99 U2 1 u1 99 U2 1 1 11 U1 99 U2—11 *P 0119�K 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 1215501-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ElB Injury and for Tow Due To Crash YR 2025I 2025-00037666 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 -n LINDEN AVE Elgin ® ❑ RELATED ❑Y ®N 06 13 2025 ®AM ❑YES ®NO U1 PRIVATE mo /day/yr 11.50 ❑PM FLOW CONDITION III_ COUNTY PROPERTY ElY ® N DOORING El #OF MOTOR 0 SLOW 15 Ixl- ®1 MI 10 E S W Bode Rd WITH VEHICLES INVLD 0 STOPPED U2 —I 0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Cook HIT&RUN I2J Y ElN PEDALCYCLIST®N ® FREE FLOW # LNS 0 18:DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 02 8 FOR DAMAGEDAREA(S) FROM TOWED U1 mo Unknown.0. Unknown Unknown 00-NONE ©, >2 �/OUETOCRASH ❑ EN NAME(LAST,FIRST,M) yr 13-UNDER CARRIAGE 1U 1 2• FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® 0 U2 02 m 9 9 SYSTEM IN 9 ENGAGED 9 15-OTHER 916-TOP 3 ' _ ❑Y ❑N CO LINK VEH. AT CRASH 99-UNKNOWN S 4 `Distraction Value 9 ALGN r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 �I COM VEH 0 j$J 2 O I- 0 9 9 FIRST CONTACT 99 7 ' __5 *If Yes.See Sidebar U1 ZUNKNOWN Unknown ' E TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 2 lii UNK. 9 UNKNOWN Unknown ®v ❑N U2 I- 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same Unknown 1 rn `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ❑ N 99 0 x DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 r My 0 KCv 0 DV 1 9 5 4 Honda Pilot 2016 00-NONE 1("j 12--_, DUE TO CRASH ❑ 2 73 0 13-UNDER CARRIAGE 10'( 2 FIRE ID El U2 C Ti F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X ❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN `0istraellon Value 9 g N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 1 6 --4 COM VEH D ® Ut CO FIRST CONTACT 6 O7 ,�=Q)O6 •IfYes.SeeSidebar C ELGIN IL 60123 0 1 0 1714353 IL 2026aR Si)0 Z IL D 0 5FNYF6H74GB084745 Travelers ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 TJADEN FAMILY LIVING 6152228872031 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) U2 996 m ##occs y / ,, U1 1 D 1 0 EV MOST DAMco AGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 11 9 06,13 /2025 11 50 ®❑PM AM in a Work Zone? ®N DIRP D 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 2 ❑ 28 03 N 3 ❑ 0 CITATIONS ISSUED 0 PENDING + ) 0 PM, El Construction SECTION CITATION NO. EMS ARRIVED TIME ❑AM El Maintenance U2 5 z —a, ARREST NAME / / _ ❑PM ' 1 ® 11 1 0 CITATIONS ISSUED PENDING UtilitySLMT oNSECTION CITATION NO. ROAD CLEARANCE TIME ❑ t 2 ❑ 0 AM ARREST NAME 061 13 12025 12 30 0 PM El Unknown work zone type U1 25 n T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 El ❑AM Workers present? ❑Y 25 1543-Sturgeon. Kyle 300 - , 1 0 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 atwn weight ht rating more than 10,000 pounds(example:truck or truckrtratler � r }----r----, s - } INDICATE NORTH ,1�1 Ii. l N 115 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } 5'j . } r r r (example:shuttle or charter bus):or 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier i O __ J _ } } } transporting employees In the course of their employment(example:employee X I A transporter-usually a van type vehicle or passenger car):or CO li III N__ �� I N } } } 4. Is used or designated to transport between 9 and 15 passengers,including the driver, • li for direct compensation(example:large van used for specific purpose):or O L L____a____J 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 m —1 CARRIER NAME Z ADDRESS 0 w Bode?Rd. CCITY/STATE/ZIPn t T - _ MOTOR CARR.ID 0 Interstate 0 Intrastate No ` !Q Scale ❑ Not in Comm./Govt. ❑ Not in Comm./Other 0 --- --1 - USDOT NO. ILCC NO. C m XI Source of above z . 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 Gray White 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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO. DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE