HomeMy WebLinkAbout2025-00049979 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 1011011001 0
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 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 1
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
0 AMENDED YR 2025I 2025-00049979 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 mE CHICAGO ST El In12:36
® ❑ RELATED ®Y 0 N 08 02 2025 ❑AM ❑YES ®NO U1 -<
g PRIVATE mo !day/yr ®PM FLOW CONDITION m
15 !MI N COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 2 co
Igi OS W South Libe,`'rh�St Cook HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
18:DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑Ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2
FOR DAMAGEDAREA(S) FROhrr TOWED U1 0
Cooper, Da ha.C. 0 2 /
yr 13-UNDER CARRIAGE �a) 2 , 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 2 m
F 2 5 ❑Y ®SNEM DUNK VEH. AT CRASHIN n ENGAGED 99-UNKNOWN 9 76•TOP 3 `Distraction Value 9 ALGN 2
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r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s iL B 4 COM VEH 0 El 2 O
F.
Hanover Park IL 60133 B 1 0 FIRST CONTACT 12 7_; _5 *IIYes.SeeSidebar U1
Z 2807711B IL 2025 REAR
TELEPHONE
IL D 2HJYK16417H533778 NIA ®Y ❑N U2 m
B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Cooper.Gerard NIA 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 XI
N DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑row 0 CIRCLE NUMBER(S) U1
Ncv ❑Dv
!1 9 9 2 Ford F150 2012 00-NONE ,�_j Qr,-_, DUE TO CRASH ❑ 2 x
o _ 13-UNDER CARRIAGE 1U) I FIRE ❑ ElU2 C
Ti
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X
❑Y 181 N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistrac on Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 I 6 !_4 COM VEH ❑ ® ut CO
FIRST CONTACT 6 7 -�-_5 •(ryes,See Sidebar C
KIRKLAND IL 60146 0 1 0 1800127B IL 2025 FIRST Si)0
Z
IL D 1 FTFW1 ETOCFA03015 State Farm ®Y ❑N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Martinez. Erica,V. 0631666SFP13 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
KNIT) (SEAT) (DOBI (SEX) {SAFT) (AIR) (INJI (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
N 1 ® 11 1 08,02 l2025 12 36 ®PM in a Work Zone? ®N DIRP co
1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
0 2 0 03 28 , ! 0 PM 0 Construction *
R 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM 0 Maintenance U2
o ® 11 1 ARREST NAME Cooper, Dajha.C. 3-707 1504000526 / ! El PM SLMT
o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility
30
r 2 ❑ 11 1 ARREST NAME AM
T 1 r ❑❑PM 0 Unknown work zone type U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 30
1504-Real, Hilario 302 08 ,28,2025 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
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
` ` --I -' r INDICATE NORTH combination):or .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ } (example:shuttle or charter bus):or
X
L A 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
rter-
y a van type vehicle or
L L.___a____.I IJ I I .. / 4alsuosedordesllnatedtotransportbetween9a dr15passengers,includingthedriver. N
} } } for direct compensation(example:large van used for speific purose):or
L L--_-a-___� - t i i 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
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M
placarding(example:placards will be displayed on the vehicle). XI
p .._. NAME
7//._Exae�ov�ra D
CARRIER Z
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ADDRESS 0
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CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
‘I. - --1 - USDOT NO. ILCC NO. m
XI
Source of above z
. If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. Xl
Xl
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? 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
Gray Red
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
_Other/Owners Residence . 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