HomeMy WebLinkAbout2025-00044247 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
El AMENDED
YR 2025I 2025-00044247 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
® ❑ RELATED ®Y 0 N 07 09 2025 ®AM ❑YES ®NO U1
N STATE ST Elgin09:19
g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FTlMI N E S W LAWRENCE AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 u)
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
0 4 !
yr 13-UNDER CARRIAGE 10 I , 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 O m
M 2 SY5 ❑Y ONM DUNK VEH. O AT CRASH IN O 15-OTHER
99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 i�6 �i 4 COM VEH ❑ j$J 2 O
1 . ELGIN I L 60120 B 1 0 FIRST CONTACT 11 7_: __5 *Ilsees.See Sidebar U1
Z S371497 IL 2025 REAR
TELEPHONE
IL D YV1 RS592172602448 State Farm ❑Y ®N U2 m
IS EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire Same 1120900-sfp-13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER 73
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Sherman ❑Y ElN 2 0
N DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 Nuv 0 NOV 0 Dv
!1 9 8 4 Jeep(after 198;;i)ind Cherokee 2023 00-NONE N_' t2 "_, DUE TO CRASH rg ❑ 2
0 13-UNDER CARRIAGE o I 2 FIRE 0 El U2 C
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 016•TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istrac)Dn Value 9
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR PONT OF
FIRST CONTACT 10 711 6 L`_5 CIOMesVSeeSidebar❑ ® U1CO
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H ELGIN IL 60120 C 1 0 ED72175 IL 2025 I 0 fp
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IL D 1C4RJHAG9PC621664 Self Insured ❑Y ®N RDEF 71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire Enterprise FM Trust NIA BAC E
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)1{ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
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U EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur ❑Y U2 Z
N 1 ® 11 1 71 ,12 125 09 18 ❑PM in a Work Zone? ®N DIRP D
1 F PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
;, 2 ❑ 36 2 25 17
! 1 ❑PM• ❑Construction *
Z 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM ❑Maintenance U2
a ® 11 1 ARREST NAME Himes. Louis. B. 11-305-A 327003200 / ! El PM SLMT
o N
❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' 0 Utility
F 2 0 ARREST NAMEAM
7 / / ❑❑PM 0 Unknown work zone type 35
U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 35
327-Hromadka.Scott 601 81 , 61 ,025 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
1. Has a weight rating more than 10,000 pounds{example:truck or truck/trailer} }---.r----; } comb nation)or
na cl INDICATE NORTH Z11
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C} } rrr (example:shuttle or charter bus):or. A \..............::_________12)
3. Is desgned to carry 15 or fewer passengers and operated by a contract carrier I O
_ } } } transporting employees In the course of their employment(example:employee X
\\\,.\\\
transporter-usually a van type vehicle or passenger car):or co
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L •---..i.. .-; d r —� - } 1. •4. Is used or designated to transport between 9 and 15 passengers,including the driver, to
I \ for direct compensation(example:large van used for specific purpose):or
L----.`- ® �, - } } } t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m
,. placarding(example:placards will be displayed on the vehicle).
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/`.\ >`: t d+ CARRIER NAME Z
//ll \ ADDRESS O
V)
\ \ CITY/STATE/ZIP 0
\ i. i. i. 1i. MOTOR CARR.ID 0 Interstate ❑ Intrastate
\ ❑ Not in Comm./Govt. ❑ Not in Comm./Other 0
--- --1 USDOT NO. ILCC NO. C
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
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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
Silver Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT' 3 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE