Loading...
HomeMy WebLinkAbout2025-00044356 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 011011000 00 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XO03881617" u, 1 U21 3 4 1 UI 7 U2 1 U, 1 u2 1 u1 1 U2 1 1 11 U1 1 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY 0 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ❑OVER 51,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED IDB Injury and/or Tow Due To Crash YR 2025I 2025-00044356 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n LARKIN AVE Elgin 03:53 ® ❑ RELATED ❑Y ®N 07 09 2025 DAM ID YES ®NO U1 -< _ PRIVATE mo /day/yr ®PM FLOW CONDITION M FT!MI N E S W N AI RLITE ST COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR ID SLOW 15 ' ❑ Kane HIT ❑V ® N WITH VEHICLES INVLD IN STOPPED U2 --I lgi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) &RUNPEDALCYCLIST IZI N ❑ FREE FLOW # LNS 0 Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 C) T�TOWED U1 0 NAME(LAST,FIRST,M) Johnson. Nicole. M. mo yr Kia Motors Co rte 2023 00-NONE ©, >2 �/OUETOCRASH ❑ EN 13-UNDER CARRIAGE 10 1 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 3 M F 2 4 SYTM❑Y ®SNE❑UNK VEH. 0 AT CRASH 0 15-99-UUNKNOWN THER9 16•T DP 3 *Distraction Value 9 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR F. POINT OF S,;il S 4 COM VEH 0 0 1 0 FIRST CONTACT 12 7_;, , _5 *IIYes.SeeSidebar Ut Z STREAMWOOD IL 60107 0 1 0 FJ72798 IL 2026 REAR TELEPHONE IL D 0 3KPF24AD2PE623246 American Freedom Insuranc ❑Y Il N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same 12-2484188-00 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused 0 Y ® N 2 0 Eg DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL ❑EWES ❑iiuv 0 i v ❑Dv CIRCLE NUMBER(S) U1 /2 Yr O 0 2 Nissan Rogue 2013 00-NONE 'o,I t2 c,�2 FIRE DUE O CRASH 0 ® U2 2 C .. 13-UNDER CARRIAGE c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X ❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN `Distracion Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 1 S .t. 4 COM VEH ❑ ® Ut CO FIRST CONTACT 6 O7 ,I=Q 14 •Iryes.See Sidebar C Z SOUTH ELGIN IL 60177 0 1 CS89915 IL 2026 i Si)0 M IL D 0 JN8AS5MVXDW107484 Nationwide ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 = Forsuk. Myriam 9112J001084 SAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP 996 < Refused RESPONDER U1 = (UNIT) (SEAT) (DOBi (SEX) {SAFT) (AIR) (INJ) 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 1 4 08 / / / UI 3 :A D / / 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 1 71 /12 125 03 53 ®AM in a Work Zone? ®N DIRP co 1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C) 0 2 28 03 / / 0 PM ❑Construction * R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 ❑AM ❑Maintenance U2 a ® 11 1 ARREST NAME Johnson. Nicole. M. 11-601-Ax S1526000555 / I El PM SLMT o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility El AM t 2 El ARREST NAME 71112 /25 04 15 ®PM 0 Unknown work zone type U1 3O 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 30 1526-Walsh.Jacob 602 81 r 61 /025 01 30 ®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. A CMV is defined asmotor vehicle used to transportand: r ----,5-••--, ; any passengers or property Z 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< } i.-- -i-- --; } } } r -, , ; ; , 1, ( INDICATE NORTH combination):or —I p1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } ' i 1 , } (example:shuttle or charter bus):or X 3. Is . L.___A_. 1 ..._.... J transporting edmployeeslin5 hecourseeo theire rsmployment example:employeener } } } transporter-usually a van type vehicle or passenger car):or co < <.__-a-_-_, , l• < <--_-a-___� , , , , 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 0 L L___-a____.: L L L ...._-..i.____� l. i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example:placards will be displayed on the vehicle). XI --I CARRIER NAME Z ADDRESS 0 T. CITY/STATE/ZIP MOTOR CARR.ID 0 Interstate ❑ Intrastate 0 ❑ Not in Comm./Govt. ❑ Not in Comm./Other O USDOT NO. ILCC NO. m XI Source of above 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? ❑ Yes II No ElUnknown 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 v 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. w Black Gold 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 DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE