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HomeMy WebLinkAbout2025-00041255 ILLINOIS TRAFFIC CRASH REPORT sheet 1 Df 6 Sheets 01111101111 I0110110000 00I DII DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0036731 3 u, 2 U21 1 1 1 U, 6 U2 1 U1 99 1_12 1 u, 1 U2 1 5 13 u,26 U2 1 *P 0119 INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW ' Elgin Police Department ONE PERSON'S ❑5501-51.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash El AMENDED YR 2O25I 2025-00041255 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME71 LILLIAN ST Elgin SECONDARY CRASH 15 ® ❑ RELATED ❑Y ®N 06 28 2025 ®AM ❑YES ® PRIVATE NO U1 mo /day/yr 01:43 ❑PM FLOW CONDITION m I0 ®!MI N Q S W South Aldine St COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n Kane HIT&RUN IZ V ❑ N WITH VEHICLESOT, INVLD DO STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 tg:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C) FOR DAMAGEDAREA(S) FRONT TOWED U1 Q Hunt. Dominque.J. 8 13-UNDER CARRIAGE ©i ©!- FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O 2 DISTRACTED 0 0 U2 2 m F 9 SYTM IN ENGAGEDTHER 4 ❑Y ®SNEDUNK VEH. O AT CRASH O 99-U15-UNKNOWN 016 3 `Distraction Value 9 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6,_iL 6 �i COM VEH 0 j$J 4 0 I . ELGIN I N I L 60123 B 1 0 FIRST CONTACT 11 7 ; __5 *Il sees.See&debar U1 Z FA25441 IL 2026 REAR TELEPHONE IL D 0 1 C4NJ PFASG D633236 None ❑Y ❑N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Elgin Fire 99 9 Same None 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Provena St.Joseph ❑Y ® N 2 0 p; DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 Nov 0 KV 0 DV CIRCLE NUMBER(S) U1 1 9 8 7 Tesla Model 3 2022 00-NONE „ ` 12 "_, DUE TO CRASH rg ❑ 2 o - 13-UNDERCARRIAGE FIRE ❑ ® U2 M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 016-TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistractlon value 9 g N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF O J. I.., 4 COM VEH ❑ ® Ut CO F„ FIRST CONTACT 11 7 _5 •If Yes.See Sidebar C ELGIN IL 60123 0 1 0 FP186088 IL 2026 I 0 Si) M IL D 0 5YJ3E1 EA4NF303796 Hertz Corporation ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Elgin Fire 99 9 Hertz.Carlos. M. 986984876 BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 I (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) U2 996 r m ##OCRs y / 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 06,28 /2025 01 43 ®❑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 v 2 ❑ 08 05 06,28 ,2025 01 49 ❑PM ElConstruction >E R O ❑ ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 3 ®AM ❑Maintenance U2 a ® 11 1 ARREST NAME Hunt. Dominque.J. 11-601-Ax 751894 06/28/2025 01 53 ❑pM SLMT I$[CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM El Utility r 2 ❑ ARREST NAME Hunt. Dominque.J. 3-707 751895 06/28 /2025 02 30 [�PM 0 Unknown work zone type U1 30 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30 1542-Chase. Ethan 701 331-Ziegler 07 ,23,2025 09 00 ❑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 nrati rating more than 10,000pound (example:truck or truck/trailer i- }----'---- ; Not 7bSold i N - INDICATE NORTH combination):or —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 < <-----I--•-•; f transporting3. Is gemployeeo sl5 or fewer In the course of passengers e e mplanoyment employee a contract ner X l 1_ f } r } transporter-usually a van type vehicle or passenger car):(example:r w L L.___a__ 9 r+ 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including C— — — - } } for direct compensation(example:large van used for specificpurpose):or [he driver, • Pe ( P 9 Pe or 0 L ' ___.I ' - t i i. , 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 71 placarding(example:placards will be displayed on the vehicle). XI CARRIER NAME Z i. ADDRESS 0 / T. clTYrsraTF�zIP n ,�ay"� - i. MOTOR CARR.ID 4. ElInterstate El Intrastate 5 I I T I C� ❑ Not in Comm./Govt. 0 Not in Comm./Other --- --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 ❑ 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 White Black u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT' 2 TOWED BY/TO. Arties/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 Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE