HomeMy WebLinkAbout2025-00046450 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003694820
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INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S El5501-S1,500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
El AMENDED
YR 202512025-00046450 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1
211 LAWRENCE AVE El® ❑ RELATED ❑Y ®N 07 18 2025 02Ag ❑AM ❑YES ®NO U1 -<
_ _ gin PRIVATE mo /day/yr ®PM FLOW CONDITION MCOUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 17 cn
❑ FT/MI NESW Kane HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD DO
U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑NW ❑!CV 0 DJ DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
T TOWED U1 Q
NAME(LAST,FIRST,M) g mo
/1 9 5 9 Ford Edge 2015 00-NONE „ 12 i DUE TO CRASH ❑ EN
13-UNDER CARRIAGE 10l• ! FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® 0 U222 m
M 2 4 ❑Y ®N SE DUNK VEH. 0 AT CRASH M IN ENGAGE0 99-UUNKNOWN 01$-TOP 3 ,Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s,_iL S �i 4 COM VEH 0 Ea 2 O
H 1- Kingston I L 60145 0 1 0 FIRST CONTACT 9 7 : __5 *lI Ves.See Sidebar U1
Z 9 DX61096 IL 2025 REAR
TELEPHONE
IL D 0 2FMTK4J9OFBB16930 All American Alliance ❑v IlN U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same Al C-9059976 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 3 0
p; DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 row 0
'1 9 4 7 Suzuki Aerio 2001 00-NONE O"i 01"O DUE TO CRASH rg ❑ 2
o 13-UNDER CARRIAGE
j I.( 2 FIRE 0 ® U2 C
c
M 5 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6-TOP®* X
❑Y ®N DUNK VEH. AT CRASH 99-UNKNOWN 8 I O Oistracton Value 9 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 7.10. 4 COM VEH 0 ® U1 CO
F,,, FIRST CONTACT 12 7�'—,AO C.
If Yes.See Sidebar
E LG I N IL 60124 B 2 8 MCY52465 IL 2025 FIRST
4 N
IL D 0 JS1 GT74A212104801 Progressive ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire Same 31144797 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER
U1 =
(UNIT) (SEAT) (D081 (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
u 1 ® 11 1 07,18 ,2025 02 49 ®AM 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 C)
v 2 0 2 28 07,18 ,2025 02 49 ®PM ❑Construction *
R 3 0 ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
z J ❑AM ❑Maintenance U2
a ® l l 1 ARREST NAME Atkinson.George.W. 11-601-Ax W1525000682 07,18 r2025 02 53 Igi pM SLMT
o N
0 CITATIONS ISSUED El SECTION CITATION NO. ROAD CLEARANCE TIME • Utility
0 AM
t 2 0 ARREST NAME 071 18 ,2025 03 06 ®PM ElUnknown work zone type U1 35
T(.0
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
❑Y 35
1525-NavE.Oscar 601 269-Mendiola , , ❑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
el ADDITIONAL UNITS FORMS.
r ----r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
I 1 _ Not To Scale 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
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
t- (example:shuttle or charter bus):or 0
r r X
3. Is designed to carry15 or fewer passengers and operated a contract carrier O
< <.___a.._.; f transportingemployees in the course of their employmentC
1 transporter-usually a van vehicle or (example:employee or X
L ...l. 1zr 4. Is used ordesi natedtotrans rtbetween9a d15nger rpassengers,a including the driver,
1 yyj- } } } for direct compensation(examp:large van used for speific purose):or 0
L t i I 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
OA - placarding(example:placards will be displayed on the vehicle). XI
I CARRIER NAME Z
ADDRESS 0
I w
I CITY/STATE/ZIP g
1 _ MOTOR CARR.ID 0 Interstate ❑ Intrastate
' ❑ Not in Comm./Govt. ❑ Not in Comm./Other 0
:- .I. --- --1 I L i. L '
USDOT NO. ILCC NO. C
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? 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
Blue 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 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE