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HomeMy WebLinkAbout2025-00047889 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets lUI III II IIII DIII 01100101111111 I IIIIIIIII DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003901565 u, 1 U21 3 4 1 u, 5 U2 1 u, 1 1_12 1 u, 1 U2 1 1 14 u, 1 u2 1 *P0119* INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW ' Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 14 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash El AMENDED YR 2025I 2025-00047889 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n KI M BALL ST Elgin 12:57 ® ❑ RELATED ®Y 0 N 07 24 2025 ❑AM ❑YES ®NO U1 —< _ _ g PRIVATE mo !day!yr ®PM FLOW CONDITION m FT!MI N E S W N GROVE AVE COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR ❑SLOW 1 (n ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0 Icy ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) y N O 0 Q NAME(LAST,FIRST,M) mo yr Dossett.Jessica. R. Ford Escape 2010 0-NONE 0• Q2 �1 OUE TO CRASH ® ❑ 13-UNDER CARRIAGE 10.I 2 FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 O m F 2 SY4 ❑Y IN DUNK VEH. O AT CRASH M IN D O 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s it S 4 COM VEH 0 j$J 1 0 F. Elgin IL 60120 0 1 0 FIRST CONTACT 12 7_;1 __5 *Irves.See Sidebar U1 Z 9 FB18341 IL 2025 REAR TELEPHONE IL D 0 1 FMCUOD7XAKC59587 Safeway ®Y ❑N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Elgin Fire Same 3484077-I L-PP-008 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER > Refused ❑Y ® N 2 c p; DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 row 0 RGV 0 DV !2 0 0 6 Kia Motors Colporento 2018 I -NONE 0. 2 j--O DUE TO CRASH rg ❑ 2 x 0 13-UNDER CARRIAGE 10 ©).. 2 FIRE 0 ® U2 C Ti M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16•TOP 3 X ❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistrac( n value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-iI�1:,-4 COM VEH ❑ ® U1 co FIRST CONTACT 12 7�_,-.5 •If Yes,See Sidebar n ELGINZ IL 60123 0 1 0 EE55694 IL 2025 RFJ M IL D 0 5XXGT4L34JG237478 Falcon ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Elgin Fire Same 0100123003-6 SAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 < Refused RESPONDER u1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 2 3 02 / F 2 5 B 1 0 m / / #OCCS > 71 / / U1 1 D / / 2 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 CD 11 1 71 ,41 /025 12 57 ®PM in a Work Zone? NJ DIRP co 1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM o If YES check one below: U1 3 C) ", T 2 ❑ 2 99 ! / ❑PM. ❑Construction Z 3 ❑ DygCITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 ❑AM Maintenance U2 ❑ o 1 ® 11 1 ARREST NAME Dossett.Jessica. R. 11-801 w1531000108 / / ❑PM SLMT I$!CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility 8 N ❑AM 30 t 2 ElARREST NAME Dossett.Jessica. R. 3-707 1531000107 / / ❑pM ❑Unknown work zone type U1 n T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ - ❑AM Workers present? ❑Y 30 1531-SchEmbach.Jack 102 / / El 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 truck trailer -< i- ;--__r-_--; INDICATE NORTH combination):or p0 J , BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver , 1 1 - (example:shuttle or charter bus):or enger car):or C 3. Is desgned to car 15 or fewer passengers and operated a contract carrier O ` `----A-•--i Not To Scale - } } . transporting employees In the courses of their employment(example:employee X L I-----}----; /,>* - } } 1 •transporter sed or des gnated to transport betweelly a van type vehicle or n 9 and 15 passengers,including the driver, �. for direct compensation(example:large van used fors specific purose):or L L____a____. - - - �. • _ _ _ 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). ;p i A rtrarovem• > CARRIER NAME Z r r 1" I i r _ ADDRESS 0rwromvmv rn I I CITY/STATE/ZIP m MOTOR CARR.ID 0 Interstate ❑ Intrastate 1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other ---------"1 - USDOT NO. ILCC NO. rn XI Source of above z . Form Number m Xl IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2 TRAILER VIN 1 m co LOCAL USE ONLY TRAILER VIN 2 m v TRAILER WIDTH(S) 0-96" 97-102" >102' m TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 o u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Gold White 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: 3 TOWED BY/TO: DUE TO ® Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE