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HomeMy WebLinkAbout2025-00039970 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II 111 I M IIIIII U I O U III III HO DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X463&61St97` u, 1 U21 2 4 1 u, 2 U299 u, 1 U2 1 u1 99 U2 99 1 10 u, 4 U2 1 *P 0119�K INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 15 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) El AMENDED ElB Injury and for Tow Due To Crash YR 202512025-00039970 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1 ® ❑ RELATED ' V 0 N 06 22 2025 DAM YES ®NO U1 -< SOUTH ST Elgin07:02 _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m FT!MI N E S W WALNUT AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLESOT, INVLD DO U2 --I El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n FOR DAMAGEDAREA(S) FRONT TOWED U1 Q Curran.William.J. 0 7 / yr 13-UNDER CARRIAGE IE 161 !!. 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® ❑ U2 2 m M 2 SY 15-OTHER 4 ❑Y ®SNE DUNK VEH. 0 AT CRASH M IN D 0 99-UNKNOWN 9 16•TOP 3 ,Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF a :iltlI 6 ,(..4 COM VEH 0 E! 4 C) .I2 Z Glendale Heights I L 60139 0 1 0 S647723 I L 2025 FIRST CONTACT 7 Oi :;LQ;_OS Yes.See Sidebar U1 0 TELEPHONE IL D 0 1 FMSK8FH5LGA49779 Erie Insurance Exchange ❑Y Igl N U2 19 . m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same Q013122314 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y El 2 0 N DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 m,lv 0 KCV 0 Dv yr Q 2 0 13-UNDER CARRIAGE 10 j ©I 2 FIRE 0 El U2 C 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 9 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-it 6 Il, COM VEH D ® U1 W FIRST CONTACT 1 Y _, _6 •(ryes,See Sidebar ~ E LG I N I L 60123 0 1 0 CW64092 I L 2025 FIRST 4 N M IL D 0 WDDHF8HB3BA431781 Allstate ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same 811621600 BAC E 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)!(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 El 11 1 06,22 i2025 07 03 ®PM AM in a Work Zone? NJ DIRP D co 1 1 PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: U1 0 T 2 ❑ 2 28 ! ! 6 n ❑AM PM• El * R 3 ❑ l�CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 ❑AM ❑Maintenance U2 o ® 11 1 ❑ ARREST NAME Curran.William.J. 11-601-Ax W1525000636 / r El PM SLMT o N 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME Utility 0 AM r 2 El ARREST NAME 06!22 /2025 07 29 ®PM El Unknown work zone type U1 3O n T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑Y 30 1525-Nave.Oscar 701 391-Jacobucci ! ! ❑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 -< ' ' 0 r INDICATE NORTH combination):or P3 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C i • Not To Scale I (example:shuttle or charter bus):or 0 L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier O - } I I- transporting employees In the course of their employment(example:employee transporter-usually a van type vehicle or passenger car):or w L L.___a____� 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including N } } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or O L i t i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m placarding(example:placards will be displayed on the vehicle). XI —1 1 — — CARRIER NAME Z ADDRESS 0V2 r 0 Gyi. n �'7 CITY/STATE/ZIP g - i. i. i. i. MOTOR CARR.ID 0 Interstate ElIntrastate 5 I I T I 0 Not in Comm./Govt. 0 Not in Comm./Other ‘I. - --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 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 Black White 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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO. DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE