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HomeMy WebLinkAbout2025-00040742 ILLINOIS TRAFFIC CRASH REPORT sheet 1 a2 Sheets 01111101111l I011011000IIII IlUhII III I1111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003667359' u, 9 U21 1 1 1 U, 2 U2 1 u,99 1_12 1 1.11 1 U2 1 5 10 u, 3 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 3 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash 0 AMENDED YR 2025I 2025-00040742 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 71 ® ❑ RELATED ❑Y ®N 06 25 2025 ❑AM ❑YES ®NO U1 S DUNDEE AVE Elgin09:47 _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION Ill 0 !MI N E S W 190 HwyCOUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 cn �C.'J O WITH VEHICLESOT, INVLD ❑ STOPPED U2 --I 0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ®V ❑ N PEDALCYCLIST®N ® FREE FLOW # LNS 0 (g)DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NOV 0!CV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0 ! ! FOR DAMAGEDAREA(S) FRONT TOWED U1 0General Motors 2004 00-NONE ©, >2 0 DUE TO CRASH ❑ EN NAME(LAST,FIRST,M) Unknown. Unknown mo yr 13-UNDER CARRIAGE 10 1 2 FIRE ❑ IE 4 < STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 m 9 3 SYSTEM IN O ENGAGED 0 15-OTHER 916-TOP 3 ' _ ❑Y (Z)N UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 i�6 4 COM VEH 0 Ea 2 O REAR Z 0 1 0 3326836B IL FIRST CONTACT 12 7_; __6 *uYes.See Sidebar U1 TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 2 111 1 GTHG39U441125959 Unknown ❑Y 0 N U2 m 5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m co Same Unknown 1 rn `o HOSPITAL(TAKEN TO) INCIDENT IF`Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER .:3D Y°N0 N 0 W N DRIVER ❑ PARKED ❑DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 Nov 0 NOV 0 DV 0 0 5 Jeep(after 19681�rokee 2016 00-NONE „ " 12'"_, DUE TO CRASH rg ❑ 2 x 0 ®13-UNDER CARRIAGE FIRE El El U2 c M 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 0916-TOP S X 0 Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i 6 i�-4 COM VEH ❑ ® U1 W FIRST CONTACT 10 Y�� ,--S •IfYes.See Sidebar C ELGIN IL 60120 0 1 0 EN18906 IL 2025 REAR Si)0 IL D 0 1C4PJMAB3GW153885 Allstate Ins ❑Y 123 N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 X Same 811806272 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPOND O N U1 = KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z co u 1 CD 11 1 06/25 /2025 09 45 ®AM in a Work Zone? NJ DIRP D 1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 5 n v 1 T 2 ❑ 2 15 I / ❑PM 0 Construction X Z 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 -a, ARREST NAME / / ❑PM ' 1 ® 1 1 1 ❑CITATIONS ISSUED ❑PENDING SLMT o N SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utilit y t 2 El ARREST NAME 06/25 l2025 09 45 ®PM 0 Unknown work zone type U1 0 AM 35 n T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ 469-Taylor,Jonathan 201 363-Vartanian , ! ❑❑PM AM Workers present? ®N U2 35 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. Dundeer �....,,....., , /YOf T 3 ? ^� A CMV is defined as any motor vehicle used to transport passengers or property and: Z J I;t-iI 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer i- }--_.r-_--; �( } combination):or —I 1 I INDICATE NORTH BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C 0 ! I - (example:shuttle or charter bus):or 3. Is designed to carry15 or fewer passengers and operated a contract carrier O }} } transporting employee �In the course of their employment(example:employee transporter-usually a van type vehicle or passenger car):or w L / I I. 4. Is used or designated to transport between 9 and 15 passengers,including C -- -- - } } } g po passen rs,includi the driver, for direct compensation(example:large van used for specific purpose):or O / / L L____a____. UnA�POt / ry l. I 1 t 5. Is any vehicle used to transport any hazardous material(HAZMAT)thatrequires m / jcs' placarding(example:placards will be displayed on the vehicle). D CARRIER NAME Z / 'Li 1585 eO ADDRESS D C) CITY/STATE/ZIP g r / ry - 1 MOTOR CARR.ID 0 Interstate 0 Intrastate 1 1 / ❑ Not in Comm./Govt. ❑ Not in Comm./Other 0 ' --- "' / i- USDOT NO. ILCC NO. C 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 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 White Black u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE El NOT DISABLING DAMAGE DAMAGE EXTENT 2 TOWED BY/TO. SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® DISABLING DAMAGE Redmons VEHICLE CONFIG._CARGO BODY TYPE LOAD TYPE