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HomeMy WebLinkAbout2025-00040692 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I011011000 0 00 lI fli lID II DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00367O3 8 u, 1 U21 3 4 1 U1 3 U2 1 U, 1 1_12 1 U, 1 U2 1 1 15 u1 1 u2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$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 El NOT ON SCENE(DESK REPORT) ® B Injury and!or Tow Due To Crash El AMENDED YR 2025I 2025-00040692 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I ® ❑ RELATED ®Y ❑N 06 25 2025 ❑AM ❑YES ®NO U1 -< LARKIN AVE Elgin05:17 _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m FT!MI N E S W N LYLE AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n ❑ Kane HIT&RUN ❑V ® N WITH VEHICLESOT, INVLD ❑ STOPPED U2 —I lgi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0 Qg3 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EDUCE ❑NOV ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 16 0 1 0 / yr 2011 Ford Expedition 00-NONE ©, 0 �/DUE TO CRASH ® ❑ 13-UNDER CARRIAGE 1U 1 • 2 FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0U2 16 M F 2 4 El ®SNE❑ is-OTHER UNK VEH. O ATCRASHIND O 99-UNKNOWN 9 16•TOP 3 `Distraction Value 9 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF & i�B 4 COM VEH 0 Ea 1 0 F. FIRST CONTACT 12 7_:---_-_(-___5 *Yves.See Sidebar U1 Z SOUTH ELGIN IL 60177 0 1 0 K225993 IL 2025 REAR TELEPHONE IL D 1 FMJU2A55BEF33476 STATE FARM ❑Y ®N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m GANOW. RONALD, L. 2974893SFP13 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER 2 ou p; DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL ❑EWES ❑NerV ❑KV 0 DV CIRCLE NUMBER(S) U1 !1 9 6 4 Honda Element 2004 00-NONE 0-, Qj'-O DUE TO CRASH rg ❑ 2 x 0 y yr 13-UNDER CARRIAGE 10( I 2 FIRE 0 ® U2 C c F 2 5 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X ❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s-il 6 I1:, 4 COM VEH ❑ ® U1 CO FIRST CONTACT 12 7� .5 •(ryes.See Sidebar H ELGIN IL 60123 0 1 0 AY24321 IL 2025 I 0 C IL D 5J6YH28534L001794 NIA 0 Y 0 N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = South Elgin Fire Same NIA SAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (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 ❑Y U2 Z N 1 ® 11 1 61 /51 /025 05 17 ®AM 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 C) 2 0 25 99 61 /51 /025 05 17 ®pm ❑Construction F R 0 ]$I CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 3 ❑AM ❑Maintenance U2 —a, ARREST NAME GANOW,CONNIE, L. 11-305-A 1554000099 61 /51 /025 05 30 Igi pM SLMT 1 ® • ❑Utility11 1 •CITATIONS ISSUED 0 PENDING o NSECTION CITATION NO. ROAD CLEARANCE TIME AM t 2 El ARREST NAME MERCEDES DE HERNANDEZ, I RMA. E. 3-707 1554000098 61 /51 /025 06 30 0 30 pM El work zone type u1 2 2 3 ❑ OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME 0 Am Workers present? ❑Y 30 1554-Wagener,Vincent 600 71 / 51 /025 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 -< ` ` ' ' ® - INDICATE NORTH combination):or —I N.71,1e)he. I. BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C 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 I O } } } transporting employees in the course of their employment(example:employee X transporter-usually a van type vehicle or passenger car):or w C L }-----}----; - I. } 1} 4. Is used or designated to transport between 9 and 15 passengers,including the driver, to t for direct compensation(example:large van used fors specific purose):or tir.,k❑ mnk� --- i ii. t 5. Is an vehicle used to trans rt anyhazardous material(HAZMAT) requires that m tl - placarding(example:placards will be displayed on the vehicle). X1 I I CARRIER NAME Z ADDRESS 0 w C) CITY/STATE/ZIP g I. nx0san... - i. MOTOR CARR.ID 0 Interstate 0 Intrastate 0 I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other ‘I. - --1 - USDOT NO. ILCC NO. m XI Source of above z . —I Were HAZMAT placards on vehicle? 0 Yes 0 No = If Yes,Name on placard O 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 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 Green 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 DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE