Loading...
HomeMy WebLinkAbout2025-00046081 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 011011000 I 111011100 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003689705 u, 1 U21 3 4 1 u, 8 U2 1 u, 1 1_12 1 u, 1 U2 1 1 10 u, 4 U2 3 *P0119* INVESTIGATING AGENCY DAMAGE TO ANY 0 5500 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 2 VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00046081 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I DUNDEE AVE Elgin06:07 ® ❑ RELATED ' ' 0 N 07 16 2025 ❑AM ❑YES ®NO U1 -< _ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION Ill FT!MI N E S W KIMBALL BALL ST COUNTY PROPERTY ❑ ® N DOORING® DOORING ❑y #OF MOTOR 0 SLOW 3 CA ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N 51 FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0 ucv ❑ce DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n 07 / yr �° Kia Motors Co rento 2020 00-NONE 12 , DUE TOCRASH ❑ EN 13-UNDER CARRIAGE 9©I I! 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 0U2 2 rl1 M 2 SYTM IN ENGAGE15-OTHER 4 ❑Y ®SNE❑UNK VEH. 0 AT CRASHD 0 99-UNKNOWN 9 76•TOP 3 *Distraction Value 9 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s.:it s �i 4 COM VEH 0 j$J 1 0 f. FIRST CONTACT 11 7_ ,__;_-_ _5 *IlYes.See Sidebar U1 Z SOUTH ELGIN IL 60177 0 1 0 CA55116 IL 2025 REAR TELEPHONE IL D 0 5XYPG4A35LG661872 STATE FARM ❑Y ®N U2 I''I in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Phorasavong.Traci. B. 1114863FSP13 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET.CITY.STATE,ZIP PHONE NUMBER RESPONDER 2711 N DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0 Iu v 0 DV '1 9 9 0 Dodge Caravan(inc Grand)2017 00-NONE 11 j t2 , DUE TO CRASH p 2 0 Yr 13-UNDER CARRIAGE 10'I 2 FIRE 0 ® U2 C c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,1,,6.TOPO3 * X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN O Distraction Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-.il�_.,_4 COM VEH ❑ ® U1 CO FIRST CONTACT 4 Y _, _5 •If Yes.See Sidebar H ELGIN IL 60123 0 1 0 AZ34515 IL 2025 RFJ0 C M IL D 0 2C4RDGCG4HR735949 KEMPER ❑Y ®N RDEF71 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 = Venegas.Yolanda 12A0001054921 SAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP u1 = (UNIT) (SEAT) (DORM (SEXI {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 1 3 06 / LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ID Z N 1 ® 11 1 07/16 r2025 06 07 ®PM 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 2 0 20 03 N 3 0 0 CITATIONS ISSUED ID PENDING + / 0 PM• ❑Construction SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 7 a ARREST NAME / / ❑PM ' - • o N 1 ® 11 1 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT 40 t 2 ARREST NAME AM 7 / / ❑❑PM 0 Unknown work zone type U1 El OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ° 456-Romalo.Carmine 301 269-Mendiola / / ❑❑PM Workers present? ®N U2 40 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 -< c ` '' -' r INDICATE NORTH combination):or -I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } I I i [ ® _ (example:shuttle or charter bus):or C 3. Is designed 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 yam, '.•�� i. transporter usually a van type vehicle or passenger car): r C L }-----}----; - - I. } } •4. Is used or designated to transport between 9 and 15 passen including the driver, to for direct compensation(example:large van used fors specific purose):or L L____a____.I .�....."R2 , t i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m _ placarding(example:placards will be displayed on the vehicle). XI -. -1 CARRIER NAME Z Not To Scale I - O Il ADDRESS 1::.of o�woee,nve CITY/STATE/ZIP 0 MOTOR CARR.ID 0 Interstate 0 Intrastate 0 I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other ; _Y_ __1 - USDOT NO. ILCC NO. m XI Source of above z . ❑ Yes 0 No 0 Unknown g D Did Carrier Safety Regulations MCS)violation contribute to the crash? A ❑ Yes No ❑ 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'; 0 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' -n TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 o u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Gray Blue u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO: _ SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO. DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE