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HomeMy WebLinkAbout2025-00045837 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 N I III InDRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003689509- u, 9 U2 3 4 9 u199 U2 U199 1_12 U,99 U2 9 6 u1 99 7 *P 0119* 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 9 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and f or Tow Due To Crash YR 2025I 2O25-00045837 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 -n LARKIN AVE Elgin ® ❑ RELATED ❑Y ®N 07 15 2025 ❑AM ❑YES ®NO U1 -< PRIVATE mo /day/yr 05:48 ®PM FLOW CONDITION m ONO/ © COUNTY PROPERTY El N. ® N DOORING ICIY #OF MOTOR 0 SLOW Cl) MI N E s N. Mclean Blvd WITH VEHICLES INVLD 0 STOPPED U2 --I El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN IZI V ElN PEDALCYCLIST®N ® FREE FLOW # LNS 0 Ig:DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0 FOR DAMAGEDAREA(S) FROM TOWED U1 0 Unknown 1 yr 13-UNDER CARRIAGE 10.I 2 FIRE ❑ NIC STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 m SYSTEM IN ENGAGED 15-OTHER 916.70P 3 9 9 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN = s 4 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF ..Ii_a I,._ 1 I— 0 9 0 FIRST CONTACT 12 7_: COM VEH 0 Ea_5 *lIVes.See Sidebar Ut 0 REAR 2 Z ' E TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED unknown ❑Y ❑N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m co 99 9 Unknown unknown 9 1- 15 HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER L O YD®N 0 0 DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 N4y 0 KCV 0 Dv yr 11-,I 12 ,- C 1 0 ❑ I' SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP 3 ❑ ❑ SPDR 0 ❑Y ❑N 0 UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value U1 9 - 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` REAR` C M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O ❑Y ❑N RDEF71 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❑YD❑N NDER U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0 / / U2 r m DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 29 9 City of Elgin Pedestrian traffic sign. 07,15 /2025 05 48 ®PM 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 � v 1 2 0 150 DEXTER CT ELGIN IL 60120 18 18 ! / ❑AM ❑Construction * Z3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 -a, ARREST NAME / / ID PM o N 0 • ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT t 2 ❑ ARREST NAMEAM 7 / / ❑❑PM El Unknown work zone type 30 U1 n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y 2 3 0 1557-Wieske. Nathan 602 391-Jacobucci ! / ❑❑PM Workers present? ®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 -< ` ` --I -' r INDICATE NORTH combination):or .Z-1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C t- (example:shuttle or charter bus):or C) 1 r N 3. Is designed to car 15 or fewer passengers and operated I a contract carrier --- ---• Not To Scale l } 1-} transporting employees � �In the courseof their employment(example:employee I- -- iX transporter-usually a van type vehicle or passenger car):or w L L.___a____.l 4. Is used ordesi natedtotrans rtbetween9and15 passengers,includingC } } for direct com nation exam I lar a van used for s �cifice ur o ):or the driver, Pe ( P 9 Pe p pose):or O L L..__a____. — w i. :. 5. Is any vehicle used to transport anyhazardous material(HAZMAT)thatrequires 'D y placarding(example:placards will be displayed on the vehicle). XI m 21. NI '� �1�� CARRIER NAME ADDRESS 0 X> C) CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate 0 Intrastate 0 1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other i— ---'._.; USDOT NO. ILCC NO. 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. XI XI 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 VIM 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—COLOR TRAILER LENGTH(S)1 ft. 2 ft. w 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_DUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO. DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE