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HomeMy WebLinkAbout2025-00046667 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 011011000011 fl 0 110 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003694O63 u, 1 U21 2 4 2 U1 2 U2 1 u, 1 1_12 1 U1 1 U2 1 1 15 u1 1 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) El Injury and/or Tow Due To Crash 0 AMENDED YR 202512025-00046667 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n LAWRENCE AVE El In 12:48 ® ❑ RELATED ®Y 0 N 07 19 2025 12,— ❑YES ®NO U1 -< g PRIVATE mo /day/yr ®PM FLOW CONDITION M FTlMI N E S W N COMMONWEALTH AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 3 Cl) ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLESOT, INVLD ❑ STOPPED U2 -I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!Cy 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n 0 5 FOR DAMAGED AREA(S) FRO T TOWED U1 O NAME(LAST,FIRST,M) Sims.Adana.C. mo / /1 9 9 9 Hyundai Sonata 2017 00-NONE ©, Q _, ODE TO CRASH IN 13-UNDER CARRIAGE } FIRE ® ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O 2 DISTRACTED 0 0 U2 2 rn F 2 SY is-OTHER 4 ❑Y ®SNE❑UNK VEH. O AT CRASH M IN D O 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _iL S 4 COM VEH ❑ j$J 1 0 ~ T ELGIN IL 60123 0 1 FIRST CONTACT 12 _: __5 *ItYes.See Sidebar U1 Z EY63820 IL 2026REAR TELEPHONE IL D 5N PE24AF5H H457296 N/A ®Y ❑N U2 M 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m co 99 9 Hill. Isaiah.J. N/A 2 r o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 c m x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 '1 9 8 1 Chrysler Pacifica 2019 00-NONE 1i_' 12.. DUE TO CRASH 0 t81 2 x o 13-UNDER CARRIAGE I FIRE ❑ ® U2 c F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 19-TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istracu n Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s-iI 6 i_i, COM VEH ❑ ® U1 CO FIRST CONTACT 2 7� _,__5 C. If Yes.See Sidebar IL 0 1 0 DB41512 IL 2025 I 0 Si) IL D 0 2C4RC1BG6KR554831 State Farm ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Same 1063090SFP13 BAC $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER u1 = (UNIT) (SEAT) (D00i (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(A.DDRESS)/(TELEPHONE! (EMS) (HOSPITAL) 1 3 11 / LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y Z N 1 ® 11 1 07/19 /2025 12 48 ®PM in a Work Zone? ®N DIRP co 1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1 cii T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 ., 2 ❑ 31 3 2 28 ! / ❑PM• 0 Construction * Z 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM 0 Maintenance U2 a ® 11 1 ARREST NAME Sims.Adana.C. 11-601-Ax 1515-000708 / / El PM SLMT • 1$!CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM• ❑Utility r 2 El ARREST NAME Sims.Adana.C. 3-707 1515-000707 071 19 /2025 02 00 0 PM 0 Unknown work zone type U1 30 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 0 AM Workers present? ❑Y 30 1515-BellEck.Stacy 601 08 ,05/2025 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. r ----r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z A _ 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< c ` -' -' I r INDICATE NORTH combination):or -I N BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C I Not To Scale J I • - (example:shuttle or charter bus):or 3. Is ned to 5 or fewer nd i. <-----;----; transporting employees inthe course passengers rhea emaployment operated xample:employee transporter} } } transporter-usually a van type vehicle or passenger car):or 03 L 4. Is used or designated to transport between 9 and 15 passengers,including C }--- ----; - } } } g po passen rs,includi the driver, for direct compensation(example:large van used for specific purpose):or L i i t _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D '---: -. placarding(example:placards will be displayed on the vehicle). D i- I Ai �' CARRIER NAME -I WsADDRESS 0 OW CITY/STATElZIP MOTOR CARR.ID ❑ Interstate ❑ Intrastate r ❑ Not in Comm./GaA. Not in Comm./Other ----------1 - USDOT NO. ILCC NO. rn XI Source of above z . 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' T TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Blue Silver u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. _Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO: DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE