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HomeMy WebLinkAbout2025-00049578 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 4 Sheets Mil III H IIII DIII 011001011111 1111 111111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0G3909164 u, 9 U21 1 1 1 U1 5 U299 U199 1_12 1 u,99 U2 1 5 9 u, 1 U221 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and f or Tow Due To Crash YR 2025I 2025-00049578 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 f7 269 ADAMS ST Elgin® ❑ RELATED ❑Y ®N 07 31 2025 DAM ❑YES ®NO U1 -< 10:25 _ g PRIVATE mo !day/yr ®PM FLOW CONDITION m COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 2 fA ❑ FT/MI N E S W Kane HIT ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I El AT RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 DRIVER (] PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 NW 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n ! ! FOR DAMAGEDAREA(S) FROM TOWED U1 O NAME(LAST,FIRST,M) mo Unknown.0. Unknown Unknown 00-NONE VI E 13-UNDER CARRIAGE 11 . 12! DUE TOCRASH ❑ yr ) FIRE 0 IE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O SYSTEM IN 9 ❑Y ❑N ❑UNK VEH. ENGAGED 15-OTHER 9 76.TOP 3 DISTRACTED 0 0 U2 2 M9 AT CRASH 99-UNKNOWN `Distraction Value ALGN = s 4 COM VEH 0 j$J r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _,1[6 !i,_ 1 0 ~ 0 9 0 FIRST CONTACT 1 7_; _5 *lI Yes.See&debar U1 REAR 2 Z ' E TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 Unknown ❑Y ❑N U2 I— in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same Unknown 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused 0 Y ® N 99 0 ❑ DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 114V 0 NOV 0 DV CIRCLE NUMBER(S) U1 yr Dodge Ram 1500(pickup) 1998 00-NONE 11 '12 _, DUE TO CRASH ❑ ! l 2 77 Ti ©-UNDER CARRIAGE FIRE ❑ ® U2 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O 2 DISTRACTEDC a SYSTEM IN 9 ENGAGED 9 15-OTHER 016-TOP 3 0 ® SPDR n ❑Y ❑N I UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 0 - N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF O I _ I. 4 COM VEH ❑ ® U1 CO F,,, FIRST CONTACT 7 Qi .s •If Yes.See Sidebar C 26664A IL 2025 REAR0 N M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 1 B7HC13Z5WJ259161 Kemper ❑Y ®N RDEF X EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 = Olguin Falcon. Felipe 12A0001017874 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 18 1 07,31 l2025 10 25 ®AM 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 U, 2 0 18 1 28 18 N 3 0 0 CITATIONS ISSUED 0 PENDING / ! ❑PM• ❑Construction SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 3 z -a, ARREST NAME / / ID PM ' o u ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT 30 t 2 0 ARREST NAME AM T 1 r ❑❑PM 0 Unknown work zone type U1 n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 - El Am Workers present? ❑Y 30 494-Kirsh. Katherine 701 , ! ❑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 unitshave been moved prior to officer's arrival. IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A I ADDITIONAL UNITS FORMS. 0 , . 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 truckrtrailer c -I r INDICATE NORTH combination)or p0 o• Q. BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C , - } (example:shuttle or charter bus):or 1 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O }} } transporting employees in the course of their employment(example:employee transporter-usually a van type vehicle or passenger car):or CO ---� � 4 I. } } 1. •4. Is used or designated to transport between 9 and 15 passengers,including the driver. N __ I , R - for direct compensation(example:large van used for specific purpose):or O AO� D i. < i. L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m I I I placarding(example:placards will be displayed on the vehicle). ;p CARRIER NAME Z ADDRESS oxtordT31. T. w c) CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate 0 Intrastate I I T I ❑ Not in Comm./Govt. Not in Comm./Other O , _Y_ Not TO Scala J ILCCNO OC amen. USDOT NO. . mamen XI Source of above z . • m 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? ❑ Yes II No ElUnknown A 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' m TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Blue u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 9 TOWED BY/TO: _ . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE