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HomeMy WebLinkAbout2025-00055447 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 4 Sheets 01111101111 I011011001 I11I1011 DIII1100 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00393.132' u, 9 U2 2 4 1 U199 U2 U199 1_12 U,99 U2 1 3 9 U1 1 U221 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 14 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and for Tow Due To Crash YR 2025I 2025-00055447 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1 BROOK ST Elgin08:06 ® ❑ RELATED ' V 0 N 08 24 2025 DAM ❑YES ®NO U1 —< _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m FT!MI N E S W SUMMIT ST COUNTY PROPERTY El ® N DOORING ❑y #OF MOTOR 0 SLOW 2 u)❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0 g DRIVER O PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 02 n FOR DAMAGEDAREA(S) FROf T TOWED U1 0mo Unknown.0. Unknown Unknown 00-NONE ©, >2 0 OUETOCRASH ❑ EN NAME(LAST,FIRST,M) yr 13-UNDER CARRIAGE 10.I 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m SYSTEM IN ENGAGED 15-OTHER 916.70P 3 9 3 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�a 4 COM VEH 0 j$J 1 0 0 1 0 FIRST CONTACT 12 7 . __5 *IfYes.SeeSidebar Ut Z Unknown ' E TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 11/ Unknown ❑Y ❑N U2 I- 5 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 r D Y°®N 0 5, 0 DRIVER I} PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 r My 0 NCv 0 DV yr Ford F150 2006 00-NONE O1 0i.O, DUE TO CRASH 0 ® 1 o 13-UNDER CARRIAGE 10,i 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.TOP 3 0 ® SPDR n ❑Y 0 N 0 UNK VEH. AT CRASH 99-UNKNOWN *Oistraglon Value U1 9 - POINT OF s "4ED CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 12 Qi;W6"%t®•CIO e1sVSeeSidebar❑ ® C 3038562B IL 2026 aR 0 Si) M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 1 FTPX14586NA01933 American Family Insurance ❑Y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Rangel-Betancourt.Abelisario 1702-8375-02 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEATI (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0 E/ MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 18 1 08,24 /2025 08 06 ®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 2 ❑ 28 20 N 1 3 0 ❑CITATIONS ISSUED 0 PENDING + ) ❑PM• 0 Construction SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM ❑Maintenance U2 —a, ARREST NAME / / 0 PM ' o u 1 ® 0 • 0 Utility1 1 1 CITATIONS ISSUED PENDINGSLMT o N SECTION CITATION NO. ROAD CLEARANCE TIME AM t 2 ❑ 18 1 ARREST NAME 08 t 24 i2025 08 06 ®PM 0 Unknown work zone type U1 15 n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ 1561-Sarovic• Mirko 102 269-Mendiola , , ❑❑PM Workers present? ®N U2 15 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 i- aooverooknt. Not To Scale I - combinationp or rating thanpounds(example:truck or truck/trailer_ more10,000 }----r--- -`--`—ic st i r INDICATE NORTH —I -1 Irk BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C i_ ` N - i. e. r ,. (example:shuttle or charter bus):or 0 I( I 4.;°:10 I 3. Is designed to carry15 or fewer passengers and operated a contract carrier O -- T _a I - } } } transporting employee in the courses of their employment(example:employee transporter-usually a van type vehicle or passenger car):or w L -----}----; 1 1 I } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver, ' I j I for direct compensation(example:large van used for specific purpose):or O ' L____a____. t i i L 5. Is any vehicle used to transport anyhazardous material(HAZMAT)thatrequires m — — — 0M— — — placarding(example:placards will be displayed on the vehicle). CARRIER NAME Z __ ADDRESS 'O V) CITY/STATElZIP MOTOR CARR.ID 0 Interstate El Intrastate I I T I ❑ 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 Gray Black 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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE