HomeMy WebLinkAbout2025-00043984 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X003882044
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 2025I 2025-00043984 VENT
ADDRESS NO. HIGHWAY or STREET NAME El ❑CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 �I
RT20 RELATED ❑Y ®N 07 08 2025 07:41 El AM El YES ®NO U1 -<
Elgin PRIVATE mo /day/yr ❑PM FLOW CONDITION m
0 !MI N E S W West LONGCOMMON Pk COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW fA
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
18: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 2 0
FOR DAMAGEDAREA(S) FROPtf TOWED U1 Q
Tihinen.Alexa. N. 0 1 /
yr 13-UNDER CARRIAGE 10 !�. 2 FIRE 0
NI
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 m
F 2 5 ❑Y ®NNE❑ IN ENGAGED
UNK VEH. 0 AT CRASH 99-OTHERWN 9 t6•TOP 3 `Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ ;il_6 ji 4 COM VEH 0 g! 1 O
~ ELG I N IL 60123 0 1 0 FIRST CONTACT 1 7 'mai-5 *II Yes.See Sidebar Ut
Z DL114AD IL 2025 ' E
TELEPHONE
IL D 0 1 FTEW2LP3SKD29565 ERIE INSURANCE ❑Y ®N U2 Mr-
Ill
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 BULL VALLEY FORD Q102040027 IL7 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
98Ai
❑ DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMy 0 KCV 0 DV
yr 12 - C
o 13-UNDER CARRIAGE 16 I 2 FIRE 0 ❑ U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 ❑ 0 SPDR 0
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value Ut 0 -
POINT OF s-.;, 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT Y�='+:=6 C•IO e1sVEH See •Sidebar❑ 0
C
CO
F` PEAR` co
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O
❑Y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
BAC
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
RESP❑YDNDER❑N U1 =
(UNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0
/ / U2 r
m
Pj
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ®Y U2 Z
u 1 ID 24 1 07,08 ,2025 07 41 Am
in a Work Zone? ❑N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 0 20 18
! , ❑PM• ®Construction *
Z3 ❑ jg CITATIONS ISSUED El PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2
-a, ARREST NAME Tihinen.Alexa. N. 11-708 W486000237 , r El PM SLMT
o N 1 0 ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility
45
t 2 ARREST NAME AM
1 r ❑❑PM 0 Unknown work zone type U1
El
7 OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME ❑Y
2 3 ❑ - ❑AM Workers present?
486-Munoz.Jasmine 800 , , ❑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 truckrtrailer -<
c ` -' -' r INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ (example:shuttle or charter bus):or
5 or fewer
< <---- -•--J. �� I LI: transporting mployeened to slIn the course passengers thir emplod yment example:employee
transporter
CO
ia0 j C
L -----}----1 or X
r - 1 sed or des gnated to translly a van type port betweeicle or n 9 and 15 enger passengers,ssen rs,including the driver,
} } for direct compensation(example:large van used for specific purpose):or
L L-- --`- J. — — — — — — - t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
D
placarding(example:placards will be displayed on the vehicle). XI
;1 :* : :i --
- CARRIER NAME Z
. . . . GO
ADCITY/STATDRESSE/ZIP —1'n
D
I
Not To Scale
MOTOR CARR.ID 0 Interstate El Intrastate
I r ❑ Not in Comm./Govt. 0 Not in Comm./Other
-----------1 - USDOT NO. ILCC NO. rn
XI
Source of above z
. 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
to
LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U_COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Adieu/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U_TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/T6
DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE