HomeMy WebLinkAbout2025-00054121 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003928 1
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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 El$501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) (83B Injury and/or Tow Due To Crash
El AMENDED
YR 202512025-00054121 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
LAWRENCE AVE Elgin
® ❑ RELATED ®Y 0 N 08 19 2025 02:41 ❑AM ❑YES ®NO U1
_ _ PRIVATE mo /day/yr ®PM FLOW CONDITION MFT!MI N E S W N CRYSTAL AVE COUNTY PROPERTY ElY ® N DOORING Ely #OF MOTOR El SLOW 1 0)0 Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUCE 0 NOV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C)
0 $ /
yr 13-UNDERCARRIAGE ) FIRE ❑ NI
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 1U O DISTRACTED 0 0 U2 0 171
M 2 SYSTM 4 ❑Y ONE DUNK VEH. O AT CRASH 0 15-99-UNKNOWN THER9 16•TOP® *Distraction Value 9 ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 7 ;il ii,4 COM VEH 0 Ea 1 0
~ McHenryIL 60050 0 1 0 FIRST CONTACT 2 7..•, *IIYes.SeeSidebar U1
Z FD11209 IL 2026 REAR
TELEPHONE
NC C 0 4T1BE46K48U235608 Geico 0 Y ® 4 U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 4352500617 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused El El 2 0
p; DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED 0 PEOAL ❑EWES 0 iiuv 0 NOV 0 DV CIRCLE NUMBER(S) U1
'1 9 8 8 Honda Civic 2007 00-NONE ,�_"j Q1-_, DUE TO CRASH ❑ 2
0 13-UNDER CARRIAGE 19( ) 2 FIRE 0 ® U2 C
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F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,1r.
6-TOP 3 X
❑Y NJ N DUNK VEH. AT CRASH 99-UNKNOWN *Oistraglon Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s_.il�.:,_4 COM VEH ❑ ® U1 CO
CONTACT 12 7 .5 •If Yes.See Sidebar
ELGIN IL 60123 0 1 0 CW71029 IL 2026 REAR 9 c
4D
IL D 0 1 HGFA16807L136049 Insurance Now ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same ILS116826600 BAc E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (D08) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((A.DDRESS)((TELEPHONE) (EMS) (HOSPITAL)
2 3 02 / M 2 4 0 1 0
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/ / #OCCS D
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur El U2 Z
N 1 ® 11 4 81 ,91 ,025 02 41 ®AM in a Work Zone? ®N DIRP co
1 t PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 1 n
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0
1
2 ❑ 2 14 , , ❑PM ❑Construction
Z3 0 igi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 7
au 1 ® 1 1 4 ARREST NAME Bishop. David. E. 11-901-A 1530000468 / / El PM SLMT
o N
❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility
15
t 2 ARREST NAME AM
T El ❑❑PM El Unknown work zone type U1
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 15
1530-Soto.Oscar 601 391-Jacobucci 10 , 71 ,025 09 00 ❑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
ID 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-_--; combination):or —I
Not To Scale INDICATE NORTH p0
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- } (example:shuttle or charter bus):or
S?Crystal?Ave x
; ; JI 3. Is designed to carry15 or fewer passengers and operated a contract carrier O
}. -A- --i `
} } } transporting employee in the course of their employment(example:employee
co
L L.___a.. transporter sed or des usually nated to ransehrt betweeicle or n 9 andr 15r) ssen rs,including[he dryer,
} } for direct compensation(examp large van used for specific purpose):or 0
_A IUnit 1\ - 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
A �. n placarding(example:placards will be displayed on the vehicle). XI
•' Unit 2- - - CARRIER NAME Z
ADDRESS 0
D
Lawrence?Ave
I
CITY/STATE/ZIP g
_ i. i. 4. MOTOR CARR.ID 0 Interstate 0 Intrastate
I I I ❑ Not in Comm./Govt. 0 Not in Comm./Other
0
USDOT NO. ILCC NO. C
m
I Source of above z
. 0 Yes No ❑ Unknown A
Was a driver/vehicle Examination Report Form completed? r
HAZMAT ❑Yes 0 No ❑Unknown Out of Service ❑Yes ❑No 7
MCS ❑Yes 0 No ❑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
Gold Gold
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 2 DUETO TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO.
DUE TO ® Other VEHICLE CONFIG._CARGO BODY TYPE LOAD TYPE