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HomeMy WebLinkAbout2025-00055603 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 1011011001 1011 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003938129` u, 1 U21 1 1 1 u1 2 U2 4 u, 8 1_12 8 u, 1 U2 1 1 2 U1 16 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ❑ON SCENE 7 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ®AMENDED ® B Injury and f or Tow Due To Crash YR 202512025-00055603 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n 9 CLOCK TOWER PLZ El In11:48 ® ❑ RELATED ❑Y ®N 08 25 2025 ®AM ❑YES El NO U1 -< g PRIVATE mo /day/yr ❑PM FLOW CONDITION m _ COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR 0 SLOW 16 u) ❑ FT!MI N E S W Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Qgl DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n 0 5 ! yr Subaru Forrester 2019 00-NONE ©1 12 OUE TO CRASH El EN 13-UNDERCARRIAGE 1 I - ! 2 FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m F 2 SY4 ❑Y ®SNE❑UNK VEH. O AT CRASM IN H O 99-UNKNOWN 9 16•TOP 3 `Distraction Value 9 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S, i�S �i COM VEH 0 j$J 1 0 F. 60110 0 1 0 FIRST CONTACT 11 7_: __5 *Ilsees.See Sidebar U1 Z CS39717 IL 2026 REAR TELEPHONE IL D 0 JF2GTACC4K8211385 Geico ❑Y ®N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Ochao.Jasmine 6154725359 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER 2 XI 0 DRIVER 0 PARKED 0 DRIVERLESS 0 PED N PEDAL 0 EWES 0 MAV 0 NOV 0 DV !2 0 0 6 Other Other 00-NONE 10 r t2 c, 2 FIRE DUE TO CRASH 0 ® U2 2 C o - 13-UNDER CARRIAGE Ti M 5 3 SYSTEM IN 0 ENGAGED 0 15-OTHER 911,6_Top 3 X ❑Y 10 N ❑UNK VEH. AT CRASH 99-UNKNOWN •Distraction Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 FIRST CONTACT 16 7�'- l. 6 IL:-.45 CIOMes.VEH See Sidebar❑ ® U1 CO •fY tO Z ELGIN IL 60120 A 9 9 REAR 3 cn IL Other 0 NIA ❑Y ❑N RDEF71 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Elgin Fire 1 99 9 Same NIA BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Provena St.Joseph 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 LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 13 5 08 125 /2025 11 48 ®❑pM in a Work Zone? ®N DIRP co I 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 0 14 18 N 1 3 0 0 CITATIONS ISSUED 0 PENDING + / ❑pM, El Construction SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 4 -a, ARREST NAME / / ❑PM ' 1 ® 13 5 0 CITATIONS ISSUED ❑PENDING UtilitySLMT o N SECTION CITATION NO. ROAD CLEARANCE TIME 0 0 AM t 2 ElARREST NAME 08 i 25 /2025 12 30 0 PM ElUnknown work zone type U1 10 n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 - ID Workers present? 0 Y 10 1540-Allah. Muhammad 401 / 0 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. .- .. , , 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_ _ , ! INDICATE NORTH combination):or p1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } - } r r (example:shuttle or charter bus):or X 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O I- I- --I--.-.� '� - y } } } transportingemployees In the course of their employment passenger car):or(example:employee w < ...l. 1 1 transporter used or designated to transport between 9 and 15 passengers,isen rs,including the driver, } } transport pa ge rwjt for direct compensation(example:large van used for specific purpose):or L ___a-.... , f ' - t i. 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m ,rr \ , placarding(example:placards will be displayed on the vehicle). :t1 10, ,,,,,,.... CARRIER NAME Z ADDRESS 0 I �.-�- l_- CITY/STATE/ZIPN MOTOR CARR.ID 0 Interstate 0 Intrastate Not To Scale O I r - 0 Not in Comm./Govt. 0 Not in Comm./Other ; _Y_ _..; USDOT NO. ILCC NO. m XI Source of above 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 Gray Black u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 1 TOWED BY/TO. SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 DUETO TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO: DUE TO ® Other/Owners Residence VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE