HomeMy WebLinkAbout2025-00057199 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets _ 01111101111 011011001 II I 0l III 0
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ® q 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)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00057199 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 71
780 VILLA ST Elgin04:35
® ❑ RELATED ❑Y ®N 08 31 2025 ❑AM ❑YES ®NO U1 —<
g PRIVATE mo /day/yr ®PM FLOW CONDITION IT1
_
COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR IR SLOW 15 rA
❑ FT/MI NESW Cook HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Qg3 DRIVER 0 PARKED 0 DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑NW ❑!CV 0 DJ DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
0 7 /
yr 13-UNDER CARRIAGE NI
10 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 0 m
F 2 4 SYTM❑Y ®SNE❑UNK VEH. 0 AT CRASH 0 15-99-UNKNOWN THER9 16•TOP 3 ,Distraction Value 9 ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s_;ij 6 ii 4 COM VEH 0 Ea 1 C)
H Z West Chicago I L 60185 0 1 0 4949276 IL 2026 FIRST CONTACT 5 7.:LQ_OS =Yves.See Sidebar Ut
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TELEPHONE
IL D 0 7FARW2H9XNE006325 AAA ❑y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same AUT701933196 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER XI
Refused 0 Y El 2 0
Eg DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑row 0 KCV ❑DV
!1 9 8 0 Jeep(after 198;;i)ind Cherokee 2023 00-NONE 11_' t2...0 DUE TO CRASH 0 2 x
0 13-UNDER CARRIAGE 10I 2 FIRE 0 ® U2 C
Ti
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `0istracton Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-it 6 ll, COM VEH ❑ ® U1 CO
FIRST CONTACT 1 Y _, _6 •(ryes,See Sidebar
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. ELGIN IL 60120 0 1 0 N889036 IL 2025 RFJ0
IL D 0 1C4RJHBG3PC505049 Allstate ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 811583812 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOB' (SEX) {SAFT) (AIR) OHM (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((A.DDRESS)((TELEPHONE) (EMS) (HOSPITAL)
1 3 06 / M 2 4 0 1 0
m
/ / ##OCCS y
71
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/ / 1 0
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 CO 11 5 08/31 /2025 04 35 ®AM 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 C)
2 ❑ 28 30
N 1 3 ❑ ❑CITATIONS ISSUED 0 PENDING + ! _ 0 PM• 0 Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 7
-a, ARREST NAME / / ❑PM '
1 ER 5 0CITATIONS ISSUED ❑PENDING •
Utilit SLMT
o NSECTION CITATION NO. ROAD CLEARANCE TIME Ely
El AM
t 2 ElARREST NAME 08/31 /2025 04 35 ®PM 0 Unknown work zone type U1 15
n 7 OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 15
1 542 Chafe. Ethan 302 391 Jacobucci / ❑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.
Not To Scare ti A CMV is defined as any motor vehicle used to transport passengers or property and: Z
r �....�,.....,
rti combination):. Hasor gmore than pounds(example:truck or truck/trailer Z 1. Has a weight ratio 10 000
r % INDICATE NORTH
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
t- (example:shuttle or charter bus):or C)
I "'— 3. Is designed to carry15 or fewer g passengers and operated by a contract carrier 0
- \ - } } } transporting employees In the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
C� C
L -----}----; - I. } 1.} 4. Is used or designated to transport between 9 and 15passengers,including the driver,
for direct compensation(example:large van used fors specific purpose):or O
__ _ _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
• a ing(example:placards will be displayed on the vehicle). XI
0
CARRIER NAME Z
ADDRESS 0
T.
CITY/STATE/ZIP C)0
® / - MOTOR CARR.ID 0 Interstate ElIntrastate
I LI.J
❑ NotinComm./Govt. NotinComm/Other USDOT NO. ILCC NO. m
XI
Source of above z
. If Yes,Name on placard O
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
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 White
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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE