HomeMy WebLinkAbout2025-00057127 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ❑OVER 51,500 El NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
El AMENDED
YR 202512025-00057127 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
® ❑ RELATED ®Y 0 N 08 31 2025 ®AM ❑YES ®NO U1
S STATE ST Elgin08:38
g PRIVATE mo /day/yr ❑PM FLOW CONDITION ITT
FT!MI N E S W NATIONAL ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR El SLOW 17 (n
❑ Kane HIT&RUN ❑Y ® 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 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0 Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 n
0 6 /
yr Q
13-UNDER CARRIAGE 16 i• : 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 0 rn
M 2 SYSTM IN ENGAGED
4 ❑Y 21 NE El UNK VEH. 0 AT CRASH 99-OTHER WN 9 16•TOP 3 ,Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S,_i� 6 �i 4 COM VEH ❑ Ea 1 0
~ ELGIN I L 60123 0 1 0 FIRST CONTACT 1 7 . __5 *II Yes.See Sidebar Ut
Z V905541 IL 2026 E
TELEPHONE
IL D JA32U8FW6AU027106 State Farm ❑v ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Cabrera. Ramon 2535187-SFP-13 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 ou
5, 0 DRIVER 0 PARKED 0 DRIVERLESS 0 PED N PEDAL 0 EWES 0 M/v 0 NCv 0 DV CIRCLE NUMBER(S) U1
yr 00-NONE 10' t2 (,�2 FIRE DUE O CRASH 0 ® U2 2 C
o 13-UNDER CARRIAGE
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M 5 3 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X
❑Y Ni N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istraction Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8- 1. 6 11: 4 COM VEH ❑ ® U1 CO
FIRST CONTACT 3 7 � �_5 •(ryes.See Sidebar C
= ELGINAR 0 cn
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IL NIA ❑y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Elgin Fire 1 51 2 Same NIA SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Sherman RESPONDER U1 =
(UNIT) (SEAT) (DOBi (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 0 Y U2 Z
N 1 ® 13 4 08,31 i2025 09 06 ®❑pM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 0 28 99
N 3 0 0 CITATIONS ISSUED 0 PENDING + ) ❑PM ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 7
-a ARREST NAME / / ID PM '
o, u ® 13 4 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT
25
r 2 0 ARREST NAME AM
7 1 r ❑❑PM 0 Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ - ❑AM Workers present? ❑Y 25
1547-Steele.Justin 701 , ❑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.
.. .. , Ar M A CMV is defined as any motor vehicle used to transport passengers or property and: Z
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1. as a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
i- }___--I-----; - - - - - combination):or
I N. I I INDICATE NORTH H
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Not To Scale ( BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver 0C
} • I _ } (example:shuttle or charter bus):or
3. Is designed to carry15 or fewer passengers and operated a contract carrier 0
} } } transporting employee �In the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or w
L }-----}----J. - I. } } } •4. Is used or designated to transport between 9 and 1 passengers,including the driver,
for direct compensation(example:large van used fors specific purpose):or
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__ _ t < < i. t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). ,Zmt
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r r -:- ''. --iti.,_!. ------ -. I' r r I-- --I- CARRIER NAME Z
IM,m�... O. - ADDRESS 0as I Lowe* C
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CITY/STATE/ZIP C)
_ i. MOTOR CARR.ID ❑ Interstate 0 Intrastate
1 I r 1 I I ❑ Not in Comm./Govt. Not in Comm./Other
� "Y""1 USDOT NO. ILCC NO. C
XI
Source of above z
. 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
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Form Number 0
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Xl
IDOT PERMIT NO. WIDELOAD' ❑Yes 0 No 2
TRAILER VIN 1 m
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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
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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE