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HomeMy WebLinkAbout2025-00041087 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I0110110000 00 IllilIl 1 11111 TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00387143 u, 9 u21 3 4 1 U, 8 U2 1 U199 1_12 1 U,99 U2 1 1 12 U1 13 U2 2 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 10 VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00041087 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 mDUNDEE AVE El01:23 ® ❑ RELATED ' V 0 N 06 27 2025 ❑AM ❑YES ®NO U1 _ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION m FT l MI N E S W CONGDON AVE COUNTY PROPERTY El ® N DOORING ❑y #OF MOTOR 0 SLOW 6 (n ❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 —I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ® FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUCE 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C) FOR DAMAGEDAREA(S) FROPtf TOWED U1 Q Unknown.O. ! ! Unknown Unknown 00-NONE ©, 12 , DUE TOCRASH ❑ EN NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE IE 10 1- !�. 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 9 9 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN = s 4 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _.Ii_S Ii,_ 1 H 0 9 0 FIRST CONTACT 11 7_: COM VEH 0 ZgJ_5 *II Yes.See&debar U1 0 REAR 2 Z ' E TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1) Unknown ❑Y ❑N U2 m 13 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 RESPONDER en Refused 0 Y El 99 0 m E{ DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 114V 0 NCV 0 Dv CIRCLE NUMBER(S) U1 !1 9 8 1 Freightliner CtYp4SD 2023 00-NONE 11__' t2 0 DUE TO CRASH ❑ 21 20 o 13-UNDER CARRIAGE 10 1 i., 2 FIRE ❑ ® U2 C M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X ❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istracton Value 9 0 POINT OF S i1 �i COM VEH 0 ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR A 5 FIRST CONTACT 1 7� -5 •If Yes.See Sidebar ROCHELLE IL 61068 0 1 0 P1209208 IL 2026 REAR 0 IL Other 7 3ALHG3FM5PDUG5109 Old Republic ❑Y ®N RDEF71 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 = Ozinga MWTB31751725 BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) 10081 (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) U2 996 r m ##occs y 71 / ,, U1 1 D 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ®Y U2 Z N 1 ® 11 1 06,27 l2025 01 23 ®PM in a Work Zone? ❑N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 2 0 20 18 N 3 0 0 CITATIONS ISSUED El PENDING + ! 0 PM• El Construction SECTION CITATION NO. EMS ARRIVED TIME ❑AM El Maintenance U2 5 -a, ARREST NAME / / 0 PM ' o N ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility SLMT 35 t 2 0 ARREST NAME AM 7 1 r ❑❑PM 0 Unknown work zone type U1 n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 - ❑AM Workers present? ®Y 35 324-Phillos.James 102 , ! ❑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 truckrtrailer -< ` ` --1 -' r INDICATE NORTH combination):or .Z-1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver ® (example:shuttle or charter bus):or r r r ` A 3. Is desgned to carry 15 or fewer passengers and operated by a contract carrier O } } } transporting employees In the course of their employment(example:employee X wraae Dundee transporter-usually a van type vehicle or passenger car):or CO 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. i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example:placards will be displayed on the vehicle). m A - _1 °'pd" CARRIER NAME Z ADDRESS 0 w n CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate 0 Intrastate 1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other -"--- - --1 - USDOT NO. ILCC NO. rn XI Source of above z . ❑ 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 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. w Red u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 2 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