HomeMy WebLinkAbout2025-00053937 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 011011001 11001101 111111
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003928669
u, 9 U2 1 1 9 U1 99 U2 U199 1_12 1 U,99 U2 1 1 9 U1 99 U221 *P 0119*
INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$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-OOO553937 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 f1
675 PAGE AVE Elgin05:49
® ❑ RELATED ❑Y ®N 08 18 2025 DAM ❑YES El NO U1 —<
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 Cook HIT ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I
&RUN
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER I] PARKED 0 DRIVERLESS 0 PED p PEDAL 0 EWES 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
! ! FOR DAMAGEDAREA(S) FRONT TOWED U1 Q
Unknown.O. Unknown Unknown 00-NONE it.. 12 , OUETOCRASH ❑ EN
NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE IE
10 ! 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED U2 2 <
9 9 SYSTEM IN 9 ENGAGED 9 15-OTHER 9 16.TOP 3 ❑ _
❑Y ❑N ®UNK VEH. AT CRASH ®-UNKNOWN `Distraction Value 9 ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S_i L s 4 COM VEH 0 0 1
0
REAR Z 0 9 UKNOWN IL FIRST CONTACT 99 7_; __5 *If Yes.See Sidebar U1
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1
UKNOWN UKNOWN ❑Y ❑N U2 I—
SI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
co
Same UKNOWN 2 m
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
'‘.30 Y°N0 N 0
5, 0 DRIVER N. PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 N4y 0 KCV 0 Dv
yr Toyota Camry 2011 00-NONE 1("j 12..-_, DUE TO CRASH ❑ 2 77
0 13-UNDER CARRIAGE 10'( 2 FIRE 0 ® U2 C
II SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR C)
SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 9 X
a ❑Y 0 N ❑UNK VEH. AT CRASH 99-UNKNOWN `0istracton Value
POINT OF 8 ) -4 ut
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR S COM VEH ❑ ® CO
F,,, FIRST CONTACT 7 O7 ,�_QI._5 •If Yes.See Sidebar
L258966 IL 2026 REAR 9 N
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
4T4BF3EK6BR088570 Allstate ❑Y ®N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
Vongsamphanh. Barry 969441737 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEATI (DOB) (SEX) {SAFT) (AIR) OM (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)r{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 08,18 /2025 05 49 ®pm 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 U1
2 0 99 99
N 3 0 CITATIONS ISSUED 0 PENDING + ❑PM• ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 3
—a, ARREST NAME / / 0 PM '
o N ® 11 1 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT
25
T 0AM
7 ❑PM ❑Unknown work zone type U1
2ARREST NAME 1 / ❑
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 — ❑AM Workers present? ❑Y 25
1519-Bae2 a.Guadalupe 201 r , ❑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 -<
r r -' -' r INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} - i. e. r r (example:shuttle or charter bus):or 0
?reetan
® 3. Is designed to carry15 or fewer passengers and operated a contract carrier O
I- <____A____� vie _ y } } . transportingemployeesinthecourseeoftheir
Not 7h SeaMemployment(example:employee w
transporter-usually a van type vehicle or passenger car):or �
L •:. .J.,.. ..; l - I. } } 1 •4. Is used or designated to transport between 9 and 15 passengers,including the driver. N
for direct compensation(example:large van used for specific purpose):or 0
L L____a____.: INm2 _ t i. i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). ;p
rmease - —I
ff70ta2Crrk CARRIER NAME Z
ADDRESS 0
U)
0
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
----'Y----1 - USDOT NO. ILCC NO. rn
73
Source of above z
. GVWR/GCWR m
0 <10,0oo 0 10,000-26,000 0 >26,000 z
Were HAZMAT placards on vehicle? 0 Yes 0 No =
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
v
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
Gray
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: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE