HomeMy WebLinkAbout2025-00042550 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets _ 01111101111 011011000 000001 III 0
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S 1215501-$1.500 0 ON SCENE 7
VEHICLE/PROPERTY ❑OVER$1,500 ®NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 2025512025-00042550 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 71
822 SUMMIT ST Elgin05:45
® ❑ RELATED 0 Y ®N 07 02 2025 ❑AM ❑YES ®NO U1
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION Ill
COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR ®SLOW 1 (n
❑ FT/MI NESW Cook HIT ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I
&RUN
❑ 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 EWES 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
/ ! FOR DAMAGEDAREA(S) .FRO Ni TOWED U1 0
unknown Unknown Unknown 00-NONE „ 12 , OUETOCRASH ❑ EN
NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 101 ! 2 FIRE El <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 m
SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3
M 2 4 ❑Y ❑N ❑UNK VEH. AT CRASH ®-UNKNOWN Distraction Value ALGN 2
$ 4 COM VEH 0 Ea r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _,I[6 !I,_ 1 00
I- 0 1 FIRST CONTACT 99 7_; _5 *IIYes.See&debar U1
REAR
2 Z ' E
TELEPHONE
UNK. Other unknown ❑Y ❑N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same unknown 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y ❑ N 99 0
g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 r uv 0 NCv 0 Dv
!1 9 6 6 Honda CRV 2024 00-NONE 0,' 12..-_, DUE TO CRASH ❑ 2 73
o 13-UNDER CARRIAGE 10 I c. 2 FIRE ID ® U2 C
II
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 19-TOP 3 X
❑Y Ni N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value 9
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-iI 6 1:, COM VEH ❑ ® U1 CO
Z FIRST CONTACT 1 Y _, _6 •(ryes,See Sidebar
H E LG I N I L 60120 0 1 0 FA96507 I L 2025 REAR
C
M
IL D 5J6RS4H47RL015049 Allstate ❑Y ®N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 802347357 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER®N U1 =
(UNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 9 07(02 l2025 07 25 ®AM 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
2 0 30 99
N 3 0 0 CITATIONS ISSUED 0 PENDING ( 1 ❑PM• ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 3
z
-a, ARREST NAME / / 0 PM '
o u ® 11 5 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
SLMT
10
t 2 0 ARREST NAME AM
7 ( 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 10
562-Hernaindez. Myra - 1 ! ❑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••--, , I A CMV is defined as any motor vehicle used to transport passengers or property and: z
Not To Scale more than pounds(example:truck or truckrtrarler
combination):or -<
1. Hasa weight rating10,000
INDICATE NORTH p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ } (example:shuttle or charter bus):or
X
i ._.; ea2Tmrmminst
3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I 0
} } } transporting employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
L L.___a____� 4. Is used ordesinatedtotrans rtbetween9and15 passengers,including C
} } 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
CARRIER NAME Z
ADDRESS 0
n
CITY/STATE/ZIP g
` i. i. i. MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
----------1 - USDOT NO. ILCC NO. m
XI
Source of above z
"" MCS c
0 Yes 0 No 0 Unknown Out of Service 0 Yes ❑No 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
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT: 9 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE