HomeMy WebLinkAbout2025-00039154 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0O3855091
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INVESTIGATING AGENCY DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ❑OVER 51,500 El NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00039154 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
187 STONEHURST DR El 03:42
® ❑ RELATED ❑Y ®N 06 19 2025 ❑AM ❑YES ®NO U1 —<
_ g PRIVATE mo !day!yr ®PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 16 u)
❑ FT/MI NESW 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
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 NIAV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
0 7 /
yr Q 12 _
13-UNDER CARRIAGE 10 1 2 VI
FIRE 0 IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 2 m
M 2 SY4 ❑Y ®SNEM IN n DUNK VEH. 0 AT CRASH 0 99-UUTHER NKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8, i�a �i 4 COM VEH 0 Ea 1 0
ELGIN I L 60120 0 1 0 FIRST CONTACT 11 7_: __5 *Ilsees.See Sidebar U1
ZDR54966 IL 2025 REAR
TELEPHONE
IL D 0 1HGCM56386A098196 GEICO ❑Y ign4 U2 I''I
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99 9 Same 6030254004 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 0
❑ DRIVER ❑ PARKED 0 DRIVERLESS 0 Pm N PEDAL 0 EWES 0 NOV 0 NOV 0 DV CIRCLE NUMBER(S) U1
yr 00-NONE 11"j Q�,-_1 DUE TO CRASH ❑ (� 2 x
o 13-UNDER CARRIAGE 10( ) 2 FIRE 0 El U2 C
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M 5 3 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y i N ElUNK VEH. AT CRASH 99-UNKNOWN *Oistrac on Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-it 6 11:,�4 COM VEH ❑ ® U1 CO
FIRST CONTACT 12 7-.�•_.5 •IfYes,See Sidebar C
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NA 0 V 0 N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
2 56 1 NA BAG $
HOSPITAL(TAKEN TO) INCIDENT RESPONDER IF'Y' OWNER STREET,CITY STATE,ZIP 996 ARefused ❑Y ®N U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 13 1 06,19 ,2025 03 42 ®AM in a Work Zone? ®N DIRP co
I I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
Eii 2 0 2 99 06,19 ,2025 03 43 PM
1 ® • ❑Construction *
Z 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
— N ®a ARREST NAME 06,19 r2025 03 48 ®pM '
1 13 1 ElUtility
0 CITATIONS ISSUED ❑PENDING SLMT
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SECTION CITATION NO. ROAD CLEARANCE TIME 0 AM
t 2 0 ARREST NAME 061 19 ,2025 03 42 ®PM ElUnknown work zone type U1 30
n 7 OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 - IDAM Workers present? ❑Y 30
1551 Dede.Joseph 202 , ❑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
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1. Has
orrating than pounds(example:truck or truck trailer 1. Has a weight more10 000 � -<
INDICATE NORTH tan): —I
I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver n
shuttl
or
Not To Scale j 3.e Is(example:designed to o carrycharter bus5 or ):or
passengers andoperated contractcarrier O
< <---- -•-•; �i 1 L.-- transporting employees inthe course tthir employment(example:employee
X
transporter-usually a van type vehicle or passenger car):or w
L 4. Is used or designated to transport between 9 and 15 passengers,including y
}-----;----; - } } } g po passen rs,includi the driver,
for direct compensation(example:large van used for specific purpose):or
L ' __-J 0 _ t i I 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires a placarding(example:placards will be displayed on the vehicle).
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{,: { CARRIER NAME Z
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CITY/STATE/ZIP 00
- MOTOR CARR.ID El Interstate El Intrastate
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I . ❑ Not in Comm./Govt. 0 Not in Comm./Other
----------- - USDOT NO. ILCC NO. rn
XI
Source of above z
. ❑ Yes II No ❑ Unknown A
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'; ElYes 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' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
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: 0 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE