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HomeMy WebLinkAbout2025-00043023 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 0110110000 HO I fl III HI DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X403878 O4 u, 1 U21 2 4 1 U, 2 U2 1 U, 1 1_12 1 U, 1 U2 1 1 15 U1 1 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 14 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash El AMENDED YR 2025I 2025-00043023 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 mDWIGHT ST Elgin 02:54 ® ❑ RELATED ®Y 0 N 07 04 2025 ❑AM ❑YES El NO U1 —< _ _ g PRIVATE mo !day!yr ®PM FLOW CONDITION MFT!MI N E S W ST CHARLES ST COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR IR SLOW 1 (n ❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑uuv ❑!Cy ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C) FOR DAMAGEDAREA(S) FRO T TOWED U1 0Hoan Xuan. N. 0 2 / yr 13-UNDER CARRIAGE ©, EN I :: FIRE 0 I23STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 rn M 2 4 SYTM❑Y ®SNE El UNK VEH. O AT CRASH 0 99-U 15- NKNOWN THER9 16•TOP 3 *Distraction Value ALGN X. r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, i�6 4 COM VEH 0 Ea 1 0 ~ ELGIN N I L 60123 0 1 0 FIRST CONTACT 12 7 ; _5 *IIYes.See Sidebar U1 Z PSL5732 TX 2025 REAR TELEPHONE IL D 0 JM3KFBCM8M0434438 State Farm ❑Y Il N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same 5852854D1953001 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER > Refused 0 Y El 2 0 g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑iiuv 0 i v ❑DV !1 9 8 7 Nissan Altima 2023 00-NONE ,1_' 12 "_, DUE TO CRASH 0 ❑ 2 0mo 13-UNDER CARRIAGE cti 2 FIRE 0 ® U2 C ll F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 016•TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF O'i' .!,_4 COM VEH ❑ ® U1 CO FIRST CONTACT 9 7 _, _5 •• •If Yes.See Sidebar C ELGIN IL 60120 0 1 0 EX48160 IL 2025 Si)0 Z IL D 0 1N4BL4DV6PN311836 Progressive ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Same 988247656 BAC $ 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) 2 3 08 / F 2 3 0 1 0 m / / #OCCS > 71 / / U1 1 D / / 2 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z u 1 ® 11 1 71 r 12 125 02 54 ®AM in a Work Zone? ®N DIRP co 1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 7 C) T 0 2 ❑ 2 99 1 / ❑PM• ElConstruction Z3 ❑ j i CITATIONS ISSUED El PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 1 o ® 11 1 ARREST NAME Hoang.Xuan. N. 11-901.01 W1535-000221 / I ❑PM SLMT o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility I 2 El ARREST NAME 71 112 125 02 54 ®PM 0 Unknown work zone type U1 3O , T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 - ❑AM Workers present? 0 Y 30 1 535 Solis• Laura 401 , r ❑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 —I r — ell combination):or more than pound (example:truck or truckrtrarler 1. Has a weight rating10 000 5 -< INDICATE NORTH BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver I- _ Not Tb Scale l (example:shuttle or charter bus):or < <---- -•-•; I4110— transporting0 gemoloyeesl5 or fewer in the course of passengers e ersnantlyntent employe a contract e I I. transporte -usually a van type vehicle or passenger car):(example:r L •-__-a---_� t I. } } } •4. Is used or designated to transport between 9 and 15passen rs,includingthedrrver, C :i11 -1 for direct compensation(example:large van used for specific purpose):or 0 L L--_-a--- ' ; t - t i I ._ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires u placarding(example:placards will be displayed on the vehicle). XI —1 1 r - 66,463,6361 CARRIER NAME Z ADDRESS O CITY/STATE/ZIPT. I MOTOR CARR.ID 0 Interstate El Intrastate I . ❑ Not in Comm./Govt. 0 Not in Comm./Other ;------ --.; USDOT NO. ILCC NO. m XI Source of above z . 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 Gray White 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 DAMAGE EXTENT: 2 TOWED BY/TO: DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE