HomeMy WebLinkAbout2025-00051402 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 011011001 I lOI HMO 11
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INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S 1215501-$1,500 ❑ON SCENE 7
VEHICLE/PROPERTY ❑OVER$1,500 ®NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 2025I 2025-00051402 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 -n
310 S MCLEAN BLVD Elgin01:03
® ❑ RELATED ❑Y ®N 08 08 2025 ❑AM ❑YES ®NO U1
_ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ FT/MI N E S W Kane HIT ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I
&RUN
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Q83 DRIVER I] PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
/ / FOR DAMAGEDAREA(S) FRONr TOWED U1 0
Unknown Unknown Unknown 00-NONE it. 12 , DUE TOCRASH 0
NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE fal !!. 2 FIRE ❑ IE <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ga U2 m
SYSTEM IN ENGAGED 15-OTHER 9 76.TOP 3
M 9 9 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN =
$ 4 COM VEH 0 Ea r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF it S �i1 0
I— 0 9 FIRST CONTACT 5 7 1 --_;_OS •IIYes.See Sidebar U1 0
c REAR
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TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1/
Unknown ❑Y ❑N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same unknown 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF`Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
r D Y°N0 N 0
m ❑ DRIVER N. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0 Ncv 0 DV
yr Chevrolet Cruze 2018 13-NONE 10 1 t2 c,-2 FIRE DUE El
CRASH 0 ® U2 2 C
o 13-UNDER CARRIAGE
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 911,6•TOP3 0 ® SPDR 0
0 Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN `Oistraci n Value U1 0
POINT OF 8 -4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6 1,:,,,COM VEH ❑ ® CO
F,,, FIRST CONTACT 5 7�_ S •If Yes.See Sidebar
ED97118 IL REAR 0 Si)
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
1 G 1 BC5SM9J7210482 Progressive ❑Y ®N RDEF .XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
99 9 Salas Gabriel. Miriam.G. 990065613 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
{UNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
U2 996 r
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/ / U1 1 D
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EV MOST EVNT DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 18 9 08/08 /2025 01 45 ®pm in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
Si 2 ❑ 18 18
N 3 0 ❑CITATIONS ISSUED 0 PENDING / / ❑PM• ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM 0 Maintenance U2
—a, ARREST NAME ! / El PM
o N 1 ® 11 5 0 •
CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT
r 2 El NAMEAM
7 1 / ❑❑PM 0 Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 El - ❑AM Workers present? 0 Y 1 O
547 Homeier.William r 1 ❑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
P3
Not7b Scale ® BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ i. e. (example:shuttle or charter bus):or
L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier O
} } } transporting employees in the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or w
L L.__-a-_- Urn4f I �'�'� 1 - � 4. Isusedordesi natedtotrans rtbetween9and15 ge ng tn} } for direct com nation exam I lar a van used fors �cifice ur rs' ):or the driver,
Pe ( P 9 Pe p pose):or O
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L i t i i m
_ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). m
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i!i I CARRIER NAME
._ ADDRESS 0
as oe+w
CITY/STATE/ZIP n
MOTOR CARR.ID 0 Interstate El Intrastate
0
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
-"-------1 - USDOT NO. ILCC NO. m
XI
Source of above z
MCS 0 Yes 0 No 0 Unknown Out of Service 0 Yes ❑No 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
Silver
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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE