HomeMy WebLinkAbout2025-00043175 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 6 Sheets 01111101111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El5501-S1,500 ®ON SCENE 7
VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and f or Tow Due To Crash YR 2025I 2025-000431755 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 m85 NATIONAL ST Elgin09:18
® ❑ RELATED ❑Y ®N 07 04 2025 DAM El YES ®NO U1 -<
_ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
COUNTY PROPERTY ®Y U N DOORING ❑y #OF MOTOR 0 SLOW 3 Cl)
❑ FT/MI NESW Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Q83 DRIVER O PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 NW 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
1 2 /
yr Ford F150 2013 -NONE i DUE TO CRASH ❑
13-UNDER CARRIAGE 10 i 12 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ ]$I U2 m
F 2 SY4 ❑Y ®SNE❑UNK VEH. 0 AT CRASIN H 0 is-OTHER
99-UNKNOWN 916•TOP3 `Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ ;ij 6 �'i 4 COM VEH 0 Ea 1 0
~ ELGIN IL 60120 0 1 0 FIRST CONTACT 6 7 ;1 __5 *IrYes.See Sidebar U1
Z M P10495 I L 2025 iivui
TELEPHONE
IL D 7 1 FTFX1 EF6DKG34545 Charter Oak Fire Ins.Co. ❑Y ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR co
a City of Elgin.City 8109160P901 1
r"o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
22 rAi
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❑ DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0
yr 12 - C
.0 13-UNDER CARRIAGE 10 1 2 FIRE 0 ® U2 C
iij c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR C)
a SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3
❑Y NJN ❑UNK VEH. AT CRASH 99-UNKNOWN *OistractlonValue 9 U1 0
POINT OF s )�I,_4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 12 Y � B `5 CIfO esVSeesideba® 0 C
CO
H TK720MYJ IN 2026 I 0 Si)
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2
0
1 GCZG H FG8G 1142364 Everest Denali Ins.Co ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
M IAN D. INC Planet P GCD0010069-251 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE;ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
/
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 18 5 07,04 r2025 09 18 ®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 30 99
N 3 0 0 CITATIONS ISSUED 0 PENDING + r 0 PM• ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 1
z
-a, ARREST NAME / / ❑PM '
o u ® 11 5 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
SLMT
15
r 2 ARREST NAME AM
7 1 r ❑❑PM 0 Unknown work zone type U1
El
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 269-Mendiola. David 401 269-Mendiola , r ❑❑AM Workers present?
®N U2 15
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'.
01. Has a weight rating more than 10,000 pounds(example:truck or truck trailer
} ----�-----1 Unit?1?hacked?Into r - combination):or
INDICATE NORTH M
}
unit?2 = g sp passengers includin the driver�---`` BY ARROW 2 Is used or desi ned to tran ort more than 15 g C
�--``` _ (example:shuttle or charter bus):or n
X
3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
- } } } transporting employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or CO
) ) I C
. 4. Is used ordesi natedtotrans rtbetween9and15 passengers, ng (/t} } for direct compensation(example:large van used for specificpurpose):or [he driver
Pe ( P 9 Pe or O
i. i ._ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). 73
Parking?lot?of?85?National - ----•- D
Street?(Metra?Station) _ CARRIER NAME Z
ADDRESS 0
cn
CITY/STATE/ZIP I n
MOTOR CARR.ID 0 Interstate 0 Intrastate -�
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other O
-----Y"": - USDOT NO. ILCC NO. m
m
' 1 Source of above Z
. If Yes,Name on placard 0
4 digit UN NO. 1 digit Hazard class No.
M
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z
own tank)? 0 Yes ® No 0 Unknown D
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes ❑ No 0 Unknown E
D
Did Carrier Safety Regulations MCS)violation contribute to the crash? p
❑ Yes lI No El Unknown 0
Was a driver/vehicle Examination Report Form completed? D
HAZMAT ❑Yes 0 No ❑Unknown Out of Service ❑Yes ®No 7(1
MCS ❑Yes 0 No ❑Unknown Out of Service ❑Yes ®No 5
Z
Form Number 0
_ m
x
IDOT PERMIT NO. WIDELOAD'; ❑Yes ®No =
' TRAILER VIM 1 _ cn
m
LOCAL USE ONLY TRAILER VIN 2 m
— O
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 0 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft N
White White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 0 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 0 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE