HomeMy WebLinkAbout2025-00044931 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
1 011011000
1 11111110111111
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003686188
u, 1 U21 1 1 2 U, 9 U2 1 U, 1 1_12 1 U, 1 U2 1 1 9 U123 U222 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 15
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
El AMENDED ElB Injury and for Tow Due To Crash YR 2025I 2025-00044931 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED ' ' 0 N 07 11 2025 ❑AM ❑YES 0 NO U1
BIRCHDALE DR Elgin05:47
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT l MI N E S W SUNSET DR COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 3 Cl)
❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD DO
U2 --I
lgi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
g DRIVER t] PARKED O DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 n
FRor4 r TOWED U1 O
NAME(LAST,FIRST,M) mo yr
Coleman.Jamal.S. Toyota Corolla 2003 0-NONE „ i DUE TO CRASH 0EN
13-UNDER CARRIAGE 101 12! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 gi U2 0 m
M 2 4 ❑Y ®SNEM❑ 15-OTHER
UNK VEH. 0 AT CRASHD 0 99-UNKNOWN 9 16•TIDP 3 *Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S iL 6 i COM VEH 0 ix) 1 0
~ ELGIN I L 60123 0 1 0 FIRST CONTACT 6 7_; __5 *II Yes.See Sidebar U1
ZEC9259 I L 2025 ' E
TELEPHONE
IL 0 1 NXBR32E73Z107421 Hugo ❑Y ®N U2 m
5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
co
99 9 Thornton. Laticia. M. HUGO-2062768 2 m
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
.:3 RESPONDER (
5, 0 DRIVER I} PARKED 0 DRIVERLESS ❑ PED 0 PEDAL 0 EWES 0 NMv 0 NCv 0 Dv
1 9 9 7 Mercedes-Ber�etris 2020' 00-NONE 'o,1 t2 (,-2 FIRE DUE O CRASH 0 ® U2 98 C o - 13-UNDER CARRIAGE
c
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 911,6•TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istraetlon Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF �'I. 6 j1:, 4 COM VEH ❑ ® U1 FIRST CONTACT 8 7 -5 *It Yes,See Sidebar C
— Elgin IL 60123 0 1 0 0336984 REAR
0 Si)
Z D
IL D 0 W1XVOBEM2L3814778 Self-Insured ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
99 9 USPS Self-Insured 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 O
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur El U2Z
N 1 ® 18 4 07,11 12025 05 47 ®pm in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 8
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
0 2 0 30 28 ) , 0 PM ❑Construction *
7
Z 3 0 Ii CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2
o ® 11 4 ARREST NAME Coleman.Jamal.S. 11-601 S1542-000343 / I El Pm SLMT
uI$[ •CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM• 0 Utility
r 2 El ARREST NAME Coleman.Jamal.S. 11-402-A S1542-000342 07,11 ,2025 05 47 ®PM El Unknown work zone type U1 30
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1542-Chace. Ethan 701 391-Jacobucci 08 , 19,2025 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 truckrtrailer -<
` `-- --I •-' INDICATE NORTH combination):or .Z�1
® BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- (example:shuttle or charter bus):or
3. Is designed to carry15 or fewer passengers and operated a contract carrier O
I- -•i Not To Scale ] - }} } transporting employee in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
L L.___a__ 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including C} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or 0
L L--_-a-___. If �l Paz ` - i. < i. L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
` placarding(example:placards will be displayed on the vehicle).
D
CARRIER NAME Z
ADDRESS 0
T.
CITY/STATE/ZIP 0
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I
0I I T I ❑ Not in Comm./Govt. ❑ Not in Comm./Other
I I
USDOT NO. ILCC NO. C
XI
Source of above z
. • m
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
co
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 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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE