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HomeMy WebLinkAbout2025-00043275 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I0110110011 ( 01111111 II IIIIIIIII DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003877976 u, 1 U21 2 4 1 U, 5 U2 1 U, 1 1_12 1 U, 1 U2 1 1 10 U1 4 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW ' Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) El AMENDED ElB Injury and f or Tow Due To Crash YR 202512025-000432755 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 m ® ❑ RELATED ®Y 0 N 07 04 2025 ❑AM ❑YES ®NO U1 —< SADLER AVE Elgin11:42 _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m FT!MI N E S W NANCY ANN LN COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 2 fA ❑ Cook HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I Igl AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NOV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C) 0 4 / yr 13-UNDER CARRIAGE ©i ! FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) EN O 2 DISTRACTED ® 0 U2 2 m M 2 SYTHER 4 ❑Y ❑SNEM®UNK VEH. 9 AT CRASH IN ENGAGED 9 99-UNKNOWN 9 16-TOP 3 ,Distraction Value 6 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6, it 6 �i COM VEH 0 j$J 1 0 ELGIN IL 60120 0 1FIRST CONTACT 11 7_:, __5 *IIYes.SeeSidebar U1 Z M P18416 IL 2000 ' E TELEPHONE IL D 0 1 FM5K8AB3LGB84209 Charter Oak Fire ❑Y Igl N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m City of Elgin 8109160P901 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER RESPONDER 6 73 x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 Nov 0 NCv 0 DV !1 9 yf 7 Ford F150 2005 00-NONE ,�_' t2"-_, DUE TO CRASH ❑ C 2 0 ®13-UNDER CARRIAGE I 2 FIRE ID El U2 C ig c M 2 4 SYSTEM IN 9 ENGAGED 9 15-OTHER 0916•TOP 3 X ❑Y ❑N Cgi UNK VEH. AT CRASH 99-UNKNOWN *Oistraglon Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR PFIRST CONTACT 1 O O`NT OF lj 6 l`_5 COMI s BeeSH idebar❑ ® UtIN C H ELGIN IL 60120 0 1 3494957B IL 2025 REAR 0 N M IL D 0 1FTPX14505NB82976 State Farm ❑Y ®N RDEF M EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same 1656189-SFP-13 BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER u1 = (UNIT) (SEAT( (DOB) (SEX) {SAFT) (AIR) (INJ) (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 u 1 ® 11 1 07 r 04 /2025 11 42 ®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 C) 2 ❑ 20 99 N 3 0 0 CITATIONS ISSUED CI PENDING + / 0 PM, ❑Construction SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5 —a, ARREST NAME r / ID PM ' o N ® 11 1 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility SLMT 20 r 2 0 ARREST NAME AM T r 1 ❑❑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 20 1539-Vargas. Miguel 302 363-Vartanian 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••--, , SedI ?Ave . 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 -< i- }---_r----; INDICATE NORTH combination):or p0 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver Unit2 Gar (example:shuttle or charter bus):or X 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O ` `""A"" ;111111: Not To Scale 1 - ; } } } transportingemployees In the course of their employment � -- P y typepassen car):(orxample:employee w transporter-usual) a van vehicle or L L.___a__._-I 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or O L L____a____. u"a1 i. < i. 5. Is any vehicle used to transport any hazardous material(HAZMAT)thatrequires m 1 1 1 placarding(example:placards will be displayed on the vehicle). ;p Navvy Ann?Ave CARRIER NAME Z ADDRESS 0 V) o CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate 0 Intrastate 1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other r -""T""1 USDOT NO. ILCC NO. rn Xl Source of above z . If Yes,Name on placard 0 4 digit UN NO. 1 digit Hazard class No. XI XI Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's Z own tank)? 0 Yes 0 No 0 Unknown T. 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? ❑ Yes II No 0 Unknown A 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' m TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 o u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Black Blue u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO: _ . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE