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HomeMy WebLinkAbout2025-00051422 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I011011001 I I DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X403917320 u, 9 U21 3 4 1 U110 U2 1 U1 99 U2 1 u,99 U2 1 1 12 u, 2 U211 *P 0119 INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S 1215501-51.500 ®ON SCENE 1 VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT) El AMENDED ❑ B Injury and f or Tow Due To Crash YR 2025I 2025-00051422 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 m ® ❑ RELATED ❑Y ®N 08 08 2025 DAM ❑YES ®NO U1 -< ST CHARLES ST Elgin03:34 _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m 0 !MI N E S W Bluff CityBlvd COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n ® OKane HIT&RUN ®Y ❑ N WITH VEHICLESOT, INVLD ® STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑uuv ❑!Cy ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n FOR DAMAGEDAREA(S) FRONT TOWED U1 Q Unknown.O. Unknown Unknown 00-NONE ©, 12 , DUE TOCRASH ❑ EN NAME{LAST,FIRST.M) mo yr 13-UNDER CARRIAGE I ! FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) OO. 2 U2 2 < 9 4 SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 DISTRACTED 0 ]$I = ❑Y ®N ❑UNK VEH. ATCRASH 99-UNKNOWN `Distraction Value 9 ALGN 6 I 4 COM VEH 0 j$J r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF iL 6 �i2 O H 0 1 0 FIRST CONTACT 11 7_: _5 *II Yes.See Sidebar U1 REAR 2 Z ' E TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 2 111 Unknown ®Y ❑N U2 I- 2. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m co 99 9 Same Unknown 1 rn `o HOSPITAL(TAKEN TO) INCIDENT IF`Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER en Refused El ® N 99 0 m g DRIVER ❑ PARKED ❑DRIVERLESS ❑ FED ❑PEDAL 0 EWES ❑ru,ly 0 NCv ❑DV 1 9 9 2 Mazda Mazda 3 2010' oo-NONE ,i_ t2 DUE TO CRASH 0 (� 2 0 Yr 13-UNDER CARRIAGE FIRE ❑ ® U2 c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X ❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istraetlon Value 9 U1 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6-iI 6 i_i, COM VEH ❑ ® CO FIRST CONTACT 2 Y -5 C. If Yes.See Sidebar ~ 60110 0 1 0 EY12608 IL 2025 REAR0 N IL A 7 J M 1 BL1 H60A1211581 Allstate ❑Y ®N RDEF71 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Same 966004150 BAC $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER u1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 11 1 08/08 �2025 03 34 ®pm in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 Eri 2 0 28 18 N 3 ❑ 0 CITATIONS ISSUED 0 PENDING + ) 0 PM- El Construction SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 5 -a, ARREST NAME / / ID PM ' 1 ® 1 1 1 ❑CITATIONS ISSUED ❑PENDING SLMT o N SECTION CITATION NO. ROAD CLEARANCE TIME ElUtilit y 0 AM T 2 ElARREST NAME 08/08 12025 03 34 ®PM ElUnknown work zone type U1 30 n T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ 1542-Chase. Ethan 401 - 1 r ❑❑AM Workers present? ®N U2 30 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 truckrtrailer -< ` ` -' -' r INDICATE NORTH combination):or -I BY ARROW 2 Is used or designed to transport more than 15 C �' g sp passengers including the driver } CIOr r r (example:shuttle or charter bus):or 3 Is designed tocarry5 fewer passengers operated contractcarrier I- L.__-A-.- -I c 1 „ } } } } transporting employees the course thm employment example:employee r '.47.11 o transporter-usually a van type vehicle or passenger car):or tNot To Scalec ' - ��� - 4. Is used or designated to transport between 9 and 15 passengers,includingto}--- ----; - } } g Po the driver, for direct compensation(example:large van used for specific purpose):or o L L--_-a-....l I l t i. i i L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m placarding(example:placards will be displayed on the vehicle). ;p —1 CARRIER NAME Z ADDRESS 0 V) 1 I 11 CITY/STATE/ZIP0 MOTOR CARR.ID 0 Interstate 0 Intrastate I r ❑ Not in Comm./Govt. 0 Not in Comm./Other ; _Y_ _-1 - USDOT NO. ILCC NO. m XI Source of above z . If Yes,Name on placard 0 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 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/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE