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HomeMy WebLinkAbout2025-00053632 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets Ill III 11 IIIIII DIII 001100001001 HIll I 101111011 DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X003924929 u, 1 U2 1 1 8 U1 5 U2 U, 1 1_12 U, 1 U2 1 6 U1 3 U2 *P 0119* 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 3 VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and f or Tow Due To Crash YR 202512025-00053632 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 71 1566 LARKIN AVE Elgin03: ® ❑ RELATED 0 Y ®N 08 17 2025 ❑AM ❑YES ®NO U1 -< 10 _ g PRIVATE mo /day/yr ®PM FLOW CONDITION MCOUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW Cl) ❑ FT/MI N E S W Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 NW 0!CV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0 0 5 ! yr 13-UNDER CARRIAGE ©,I :: FIRE ElIE C STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 Ea U2 m F 2 4 ❑Y ®SYNNEM IN n❑UNK VEH. O ATCRASHH D 0 99-UUTHER NKNOWN 9t6•Top 3 `Distraction Value 9 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s it s ii,4 COM VEH 0 Ea 1 0 0 ELGIN I N I L 60123 0 1 0 FIRST CONTACT 11 7_:, -__5 *Il ves.See Sidebar U1 Z EN37804 IL 2025 REAR TELEPHONE IL D 0 2C4RDGCGOGR312025 Progressive El IglN U2 I- 5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same 994107981 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ® N 2 ou 0 DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMV 0 Ncv 0 DV yr 12 _ C o 13-UNDER CARRIAGE 10 I 2 FIRE 0 ❑ U2 C c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 0 ❑ SPDR 0 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value U1 0 - POINT OF s-.;, 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT Y.='+:-5 COM•I sVEH See •Sidebar❑ ❑ C CO F` ---- co M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O ❑Y ❑N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = BAC HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < RESP❑YD❑N NDER U1 = (UNIT) tSEATI (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0 / / U2 r m Pj / 0 EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z U 1 ❑ 36 1 City of Elgin Pedestrian Crossing Sign 08,17 ,2025 03 10 0 AM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 4 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 ,, ;, 2 ® 34 5 150 DEXTER CT ELGIN IL 60120 28 18 ! / ❑PM• ❑Construction * t Z3 ❑ El CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 -a, ARREST NAME Lewis.Tynesha. N. 11-601 W1542-000403 ! ! El PM SLMT o u 1 ❑ 0 CITATIONS ISSUED PENDING Utility o N SECTION CITATION NO. ROAD CLEARANCE TIME • 0 t 2 ❑ ARREST NAME 08!17 /2025 03 10 0 PM El Unknown work zone type U1 30 n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y 2 3 ❑ ID AM Workers present? ❑ 1542 Chafe. Ethan sot 269 Mendiola , , ❑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••--, , N 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 -< i- ;.____r____1 Not r Seale- combination):or � INDICATE NORTH p3 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C _ } (example:shuttle or charter bus):or X i i 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O - y } l- . transportingemployees in the course of their employment pbymar):or(example:employee w i. ...I. f 1 transporter sed or d usually designated to transport betweeicle or n 9 and 15r) ssen rs,including the dryer, C hr�^ t j r } } } for direct compensation(examp large van used for specific purpose):or O L L--_-a-.... I.'IAli'i+- r L i. } i. L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m r placarding(example:placards will be displayed on the vehicle). r J r CARRIER NAME Z ADDRESS 'n C) CITY/STATE/ZIP g :�, _ 1 MOTOR CARR.ID 0 Interstate 0 Intrastate 5 I r ❑ Not in Comm./Govt. ❑ Not in Comm./Other 0 ;____Y_._-1 - USDOT NO. ILCC NO. m Xl Source of above z . If Yes,Name on placard O 4 digit UN NO. 1 digit Hazard class No. XI XI 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 VIM 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_COLOR TRAILER LENGTH(S)1 ft. 2 ft. w White u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 2 TOWED BY/TO: _ SELECT CODES FROM THE BACK OF CRASH BOOKLET U_DUE ETOO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO.DUE T VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE