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HomeMy WebLinkAbout2025-00057209 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 a Sheets 01111101111 011011001 0 fl II 1111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003943088 u, 1 U21 1 1 1 U1 2 U216 U, 1 1_12 1 U, 1 U2 1 1 10 u1 1 U2 4 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT) El AMENDED ❑ B Injury and f or Tow Due To Crash YR 2025I 2025-00057209 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n 104 S STATE ST Elgin05:17 ® ❑ RELATED ❑Y ®N 08 31 2025 ❑AM ❑YES El NO U1 —< _ PRIVATE mo /day/yr ®PM FLOW CONDITION m COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR IR SLOW 1 (n ❑ FT/MI NESW Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0 Q83 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 0 C) FOR DAMAGEDAREA(S) FROM TOWED U1 I� Stewart.Ton m. 1 2 / yr 13-UNDER CARRIAGE ©,I :: FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 0 m M 2 SY4 ❑Y ®SNE UNK VEH. 0 AT CRASH M IN ENGAGED0 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, i�6 4 COM VEH 0 Ea 1 O ~ ELGIN I N I L 60123 0 1 0 FIRST CONTACT 12 7 • _-5 *Ir Yes.See Sidebar U1 ZBD64852 IL 2025 E TELEPHONE IL D 0 1 FADP3K25HL281760 Progressive ❑Y I l N U2 13 . m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same 977216862 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused 0 Y El 2 0 x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMv 0 KCV 0 DV !1 9 5 8 Honda Fit 2020 ay Yr ' 00-NONE 11_"j 12..-_, DUE TO CRASH ❑ 2 x 0 13-UNDER CARRIAGE 10 i 2 FIRE ❑ ElU2 C Ti F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 91 16-TOPO3 * X ❑Y i N 0 UNK VEH. AT CRASH 99-UNKNOWN O Oistracton Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8- 1. 6 I, 4 COM VEH ❑ ® U1 CO FIRST CONTACT 4 7� ,-OS C. If Yes.See Sidebar ELGIN Z IL 60123 0 1 0 DH58050 IL 2025 REAR— 0 M CO D 0 3HGGK5H48LM731923 State Farm ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Same 0079458SFP13 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(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 CD 11 5 08,31 /2025 05 17 ®PM in a Work Zone? NJ o1RP co 1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 1 C) T 2 ❑ 2 99 1 1 0 PM ❑Construction * Z 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 4 ❑AM ❑Maintenance U2 -a, ARREST NAME / / ElPM ' 1 ER 5 0CITATIONS ISSUED ❑PENDING • Utilit SLMT o NSECTION CITATION NO. ROAD CLEARANCE TIME Ely I 2 0 ARREST NAME 08/31 12025 05 20 0 PM El Unknown work zone type U1 0 AM 1 O n T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ° 1528-Rivera. Kevin 701 269-Mendiola / ❑❑PM Workerspresent7 0 N U2 10 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 truck trailer -< ` ` --1 -' r INDICATE NORTH combination):or .Z-1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C Z - (example:shuttle or charter bus):or L A war sar._ 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O .___ J - } } } transporting employees in the course of their employment(example:employee X transporter-usually a van type vehicle or passenger car):or w C L L.___a__._. u 4. Is used ordesi natedtotrans rtbetween9and15passengers,includingthedriver, 1 rtima r , } } } • for direct compensation(example:large van used for speific purose):or L -a-___. wm»r - t i. ii. , 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires •u wwnsmm m — — + placarding(example:placards will be displayed on the vehicle). XI M , Z CARRIER NAME Z ADDRESS 0 V) C) CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate 0 Intrastate 0 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 ❑Yes 0 No 0 Unknown Out of Service ❑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 Red 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: 1 TOWED BY/TO. DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE