HomeMy WebLinkAbout2025-00038844 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 011011000001 fl III 0
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003662083
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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 El$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 2025I 2025-00038844 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME
SUMMIT ST Elgin SECONDARY CRASH 15
® ❑ RELATED ❑Y ®N 06 18 2025 ®AM ❑YES ®NO U1 -<
PRIVATE mo /day/yr 11.34 ❑PM FLOW CONDITION m
025 0/MI N E S ® HIAWATHA Dr COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 2 co
Cook HIT&RUN ❑V ® N WITH VEHICLESOT,
INVLD DO
STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
18:DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EDUCE ❑NOV ❑Ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0
FOR DAMAGEDAREA(S) FROM T TOWED U1 Q
NAME(LAST,FIRST,M) Smith.Otis.S. mo 0 6 / '1 9 Y 0 Nissan Rogue 201 5 00-NONE ,1, O _, ODE TO CRASH ® ❑
13-UNDER CARRIAGE 1a i , 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 4 rn
M 2 SY n is-OTHER
5 ❑Y ®SNE M DUNK VEH. AT CRASH IN n D 99-UNKNOWN 9 76•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S_iL S 4 COM VEH 0 j$J 1 0
~ ELGIN I L 60123 B 1 0 FIRST CONTACT 12 7_; __5 *II Yes.See Sidebar U1
Z EU56754 IL 2025 PEAR
TELEPHONE
IL D 0 5N 1 AT2MVXFC819940 DIRECT AUTO ®Y 0 N U2 1--
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 99 9 VARRETTE.SHERANESE.A. PAIL001201136 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 73
p; DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑NMV 0 NOR ❑DV
2 0 0 2 Chevrolet Avalanche 2002 00-NONE 11_"j Qr,-_, DUE TO CRASH 0 ❑ 2 x
o 13-UNDER CARRIAGE 1U) I FIRE ❑ El U2 C
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S I S .!.,_4 COM VEH ❑ ® Ut CO
FIRST CONTACT 6 7 -_5 •(ryes.See Sidebar C
Z ELGIN0 IL 60120 B 1 0 2021946B IL 2025 PEAR Si)
D
IL D 0 3GNEK13T52G293914 STATE FARM ❑Y ®N RDEF M
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire 99 9 POZOS. RAFAEL 0168827-SFP-13 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
ui =
(UNIT) (SEAT) (008) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 06/18 /2025 11 34 ®❑PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1 �
2 0 11 1 28 03 06,18 /2025 11 34 PM
❑ ❑Construction
R O 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
3 ®AM ❑Maintenance U2
ARREST NAME Smith.Otis.S. 11-601 374001322 06/18/2025 11 41 ❑PM SLMT
au 1 ® 11 1 lgi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM El Utility
t 2 0 11 1 ARREST NAME Smith.Otis.S. 3-707 374001323 06/18 /2025 12 16 ®PM 0 Unknown work zone type U1 35
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM workers present? 0 Y 35
374 Rizzu o. Michael 201 08 ,05/2025 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.
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 -<
c ` --I -' r INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
7a+ - (example:shuttle or charter bus):or 0
Not To Scab j r r r
I- I- --I--•--I \ i I,. transportingtlgemployeeso lin the course 5 or fewer passengers
�heir a employmentnd example:employee
a contract CO
ner
} F
suMMirisr Rp transporter-usually a van type vehicle or passenger car):or
�— tmrr1 - } 1. •4. Is used or designated to transport between 9 and 15 passengers,including the driver, N
— — — — for direct compensation(example:large van used for specific purpose):or O
L L____a____. — 8 r uam J 4' t i t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
m
�
placarding(example:placards will be displayed on the vehicle).
` CARRIER NAME Z
ADDRESS O
14.1
r
CITY/STATE/ZIP 0
MOTOR CARR.ID 0 Interstate 0 Intrastate
I r ❑ Not in Comm./Govt. 0 Not in Comm./Other
--- --1 - USDOT NO. ILCC NO. m
XI
Source of above z
. If Yes,Name on placard 0
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
T.
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
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
Red Blue.Dark
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE