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HomeMy WebLinkAbout2025-00056077 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Df 2 Sheets 01111101111 I011011001 I0fl 0 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X403938541 u, 1 U21 1 1 1 U1 4 U2 1 U, 1 1_12 1 U, 1 U2 1 1 11 U1 14 U211 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW ' Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT) El B Injury and f or Tow Due To Crash El AMENDED YR 2025I 2025-00056077 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rl ® ❑ RELATED ®Y 0 N 08 27 2025 ®AM YES ®NO U1 -< E CHICAGO ST Elgin07:34 _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION Ill FT!MI N E S W CAMPUS DR COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 cn ❑ Cook HIT ❑Y ® N WITH VEHICLES INVLD IN STOPPED U2 --I El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) &RUN PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n 0 8 / Mitsubishi Galant 2012 oo-NONE 1.,.. ©' DUE TOCRASH ® ❑ E 13-UNDER CARRIAGE 10 i : 2 FIRE 0 NI STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m F 2 SY n is-OTHER 4 ❑Y ONM❑UNK VEH. AT CRASH IN n D 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $,_iL 6 �i COM VEH 0 j$J 1 0 ~ ELGIN IL 60123 0 1 0 FIRST CONTACT 1 7 ; __5 *IIYes.SeeSidebar U1 Z EQ47587 IL 2026 REAR TELEPHONE IL D 0 4A32B3FF5CE008809 Progressive ❑Y ®N U2 33 . m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Elgin Fire 99 9 Same 990025060 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y El 2 0 p; DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uv 0 NCv 0 Dv CIRCLE NUMBER(S) U1 yr 13-UNDER CARRIAGE 10;1 2 FIRE ❑ ® U2 C c F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP 3 ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistrac on Value 9 0 POINT OF s iI 4 COM VEH D ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR - (AV_ FIRST CONTACT 6 Y__{_ _5 •IfYes,SeeSidebar Z Streamwood IL 60107 0 1 0 5382746 IL 2026 REAR 0 C M IL D 0 5J6RE4H31 BL015097 Horace Mann ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Elgin Fire 99 9 Same 650000068510101 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 1 81 ,71 ,025 07 34 ®❑pM in a Work Zone? ®N DIRP co 1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1 C) 453. 2 0 28 14 81 ,71 ,025 07 34 ❑PM 0 Construction * 4 R 3 0 $I CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ®AM 0 Maintenance U2 o ® 11 1 ARREST NAME Hinton.Tamilla 11-601-Ax 1560000072 81 ,71 r025 07 38 ❑PM SLMT o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility AM 40 r 2 0 ARREST NAME 81 171 ,025 08 00 MPM ElUnknown work zone type U1 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 40 1560-Jones. Bennett 302 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 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 truckrtrailer -< i- -- --I-- --; C•mpus9G.. - INDICATE NORTH combination)or .Z� } 1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C - } (example:shuttle or charter bus):or T, . A } 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O } } transporting employees in the course of their employment(example:employee X transporter-usually a van type vehicle or passenger car):or w LL____a Not To Scale 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y 1. } } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or 0 L 4—z t i i ._ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D NM . , , . placarding(example:placards will be displayed on the vehicle). XI —I CARRIER NAME Z ADDRESS 0 V) CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate 0 Intrastate I ❑ Not in Comm./Govt. Not in Comm./Other o i i, i - : : : ❑_Y____ E.7p i Q ml. i. ' USDOT NO. ILCC NO. m r XI Source of above Z . If Yes,Name on placard 0 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 to 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 White Silver u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. _Arties/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO: DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE