HomeMy WebLinkAbout2025-00057567 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Df 2 Sheets 01111101111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) (83B Injury and/or Tow Due To Crash
0 AMENDED YR 202512025-00057567 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
ALFT LN Elgin
® ❑ RELATED ❑Y ®N 09 02 2025 ®AM ❑YES El NO U1 -<
PRIVATE mo /day/yr 07:08 ❑PM FLOW CONDITION ITT
010Q/MI N O S W Westfield Dr COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR IR SLOW 6 Cl)
Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 -I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS O
183 DRIVER (] PARKED O DRIVERLESS 0 PED 0 Peoa_ 0 EouES 0 NOV 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
1 0 /
Honda Accord 2010 00-NONE 11_' Q ITT 0 DUE TO CRASH ® ❑
13-UNDER CARRIAGE 10 i FIRE ❑ tz
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® 0 U2 rn
F 2 SY5 ❑Y ONM❑UNK VEH. O AT CRASH IN O 99-UNKNOWN 9 16•TOP 3 *Distraction Value 6 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ :i1 a �i, COM VEH 0 j$J 1 0
~ ELGIN N I L 60123 B 1 0 FIRST CONTACT I 7_; __5 *IIYes.See Sidebar U1
Z CZ48098 IL 2025 Ismi
TELEPHONE
IL D 1 HGCP2F30AA127544 USAA ❑Y ®N U2 19 . m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire Gamalinda. Luis. P. 0166442247104 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
. Refused RESPONDER
XI
0 DRIVER X. PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 NMV 0 NOV 0 DV CIRCLE NUMBER(S) U1
yr 13-UNDER CARRIAGE 10,i 12 , 2 FIRE ❑ ® U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL)
9 16•TOP 3 DISTRACTED ❑ El SPDR n
0 0
SYSTEM INENGAGED15-OTHER 9
a D Y NJ ❑UNK VEH. AT CRASH 99-UNKNOWN •Oistractlon Value
POINT OF 8._1� ' 4u1
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR S !_ COM VEH D ® CO
F,,, FIRST CONTACT I 7�__�__5 •(ryes,See Sidebar
P1305893 IL 2025 I 0Si)
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
1 FDOX5HT2REG02398 Travelers Property and Ca ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER I =
Western Utility Cont VTC2JCAP2W268286TIL2 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP 996 <
ND
0 Y°0 N U1 =
(UNIT) (SEAT) (DOBI (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
W 08 /
0 O
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ®Y U2Z
N 1 ® 18 1 09 102 /2025 07 08 ®❑pm in a Work Zone? ❑N DIRP co
I I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 ❑ 14 99
N 3 ❑ CITATIONS ISSUED 0 PENDING + / ❑PM ❑Construction >F
SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM ®Maintenance U2
-a, ARREST NAME / / ❑PM '
o N El 11 1 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT
30
t 2 ARREST NAME AM
7 1 / ❑❑PM ❑Unknown work zone type U1
El
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ - ❑AM Workers present? ®Y 30
327 Hromadka.Scott sot , / ❑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----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 -<
r r -r -, r INDICATE NORTH combination):or -I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- } (example:shuttle or charter bus):or
,
r r
3. Is designed to carry15 or fewer passengers and operated a contract carrier 0
. - - --
till - }} } transporting employee � �In the courseof their employment(example:employee �
} A i X
transporter-usually a van type vehicle or passenger car):or w
L L.__-a__ unit 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including C} } for direct compensation(example:large van used for cific ur mdudi the driver,
Pe ( P 9 Pe purpose):or O
L -a-...� — — - t i I 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
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m
unit,
placarding(example:placards will be displayed on the vehicle). XI
—1
CARRIER NAME Z
ADDRESS 0j D
Not To Scale I w
CICITY/STATE/ZIPC)g
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
‘I. - --1 - USDOT NO. ILCC NO. m
XI
Source of above z
.
Were HAZMAT placards on vehicle? 0 Yes 0 No =
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 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: 3 TOWED BY/TO:
DUE TO ,,--a
Other/Unknown VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE