HomeMy WebLinkAbout2025-00037880 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0O38550799
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INVESTIGATING AGENCY DAMAGE TO ANY ❑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 1
VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00037880 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED ❑Y ®N 06 14 2025 ®AM ❑YES ®NO U1
RIPPLE BROOK LN Elgin10:24
g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
10 !MI N E S W North Ripple Brook Ct COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 Cl)
® pp Cook 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 ID PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 NOV 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FOR DAMAGEDAREA(S) FROM TOWED U1 O
NAME(LAST,FIRST,M) g
Au us n Magdalena. mo /1 9 8 3 Subaru Outback 2021 00-NONE ,, • 12 , DUE TO CRASH ❑ tzl
13-UNDER CARRIAGE FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED 0 0U2 2 m
F 2 4 El ®SNE❑LINK VEH. 0 AT CRASH IN ENGAGED0 99-UUNKNOWN 9 16-TOPO `DistractionValue ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR
F_ FIRST CONTACT 3 7 POINT OF 6• iI 6 it®COM VEH 0 El 4 C)
_,--_;_OS •0Yes.See Sidebar U1 0
... ELGIN IL 60120 0 1 0 CJ31033 IL 2025 REAR
TELEPHONE
IL D 0 4S4BTAFC1 M3122017 American Family ❑Y ®N U2 13 . m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 2538782101 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER XI
Refused ❑Y ® N 1 c
0 DRIVER X. PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 uv 0 NOV 0 Dv
yr 12 _
o — 13-UNDER CARRIAGE 101 2 FIRE ❑ ® U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN 0 ENGAGED 0 15-OTHER p16-TOP 3 0 ® SPDR n
❑Y ®N DUNK VEH. AT CRASH 99-UNKNOWN `Oistraglon Value 0 -
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF O I . 4 COM VEH ❑ ® Ut CO
F,, Q i� .s •If Yes.See Sidebar C
DL754BH IL 2025 REAR0 N
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
3G NAXLEGXTL133516 Progressive ❑Y ®N RDEF X/
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER I =
ZEIGLER CHEVROLET 973638665 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP 996 <
RESPONDER
Y°®N U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),{ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 18 1 06,14 l2025 10 24 ®❑PM in a Work Zone? ®N DIRP co
I 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)
o"
2 28 18 ) ! ❑PM ❑Construction *
Z 3 ❑ xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
ou ® 11 1 ARREST NAME Augustyniak. Magdalena.A. 11-601 465-463 / ! El PM SLMT
S' N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility
25
t 2 ARREST NAME AM
T 1 r ❑❑PM 0 Unknown work zone type U1
El
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 0 AM Workers present? ❑Y 25
465-Dorado.Ariana 201 07 , 15,2025 01 30 ®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.
A CMV is defined asmotor vehicle used to transportand:
r ----,5-••--, ; any passengers or property
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1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
} i.-- -i-- --; } } } r -, , ; ; , 1, ( INDICATE NORTH combination):or —I
p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ' i 1 , } (example:shuttle or charter bus):or
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3. Is
. L.___A_. . ..._- - . transporting edmployeeslIn5 hecourseeo theire rsmployment example:employeener
} } }
transporter-usually a van type vehicle or passenger car):or co
< <.__-a-_-_, , l• < <--_-a-___� , , , , 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or 0
L L___-a____.: L L L ...._-..:_____� 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
T.
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other O
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
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LOCAL USE ONLY TRAILER VIN 2 m
v
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. w
White Black
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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE