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HomeMy WebLinkAbout2025-00058501 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 1011011001 I0H 0011000 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003951500 u, 9 u21 1 1 1 U, 2 U2 1 U199 1_12 1 U1 99 U2 1 1 11 U1 1 U211 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 3 VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT) El AMENDED ❑ B Injury and for Tow Due To Crash YR 2025I 2025-00058501 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ® ❑ RELATED PRIVATE 0 Y ®N 09 05 2025DAM ❑YES ®NO U1 -< RT20 WB I ILLINOIS AVE Elgin mo /day/yr 07:02 ®PM FLOW CONDITION m 010(�!MI N E O W Rt 20 and Illinois Ave COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 15 u) Cook HIT&RUN ®Y ❑ N WITH VEHICLES INVLD ® STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 18:DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEOAL ❑EWES ❑NOV ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n FOR DAMAGEDAREA(S) FROM TOWED EN U1 0De Lara.An eles.A. 0 2 / yr 13-UNDER CARRIAGE ©,I :: FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m F 9 9 15-OTHER ❑Y ®N SYSTEM ❑UNK VEH. 0 AT CRASH D 0 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 F. FIRST CONTACT 12 7 .— _5 *Ir Yes.See Sidebar U1 Z Warrenville IL 60555 0 9 0 ER37659 IL 2026 TELEPHONE IL D 4T1 BF1 FK7FU078973 Unknown ❑Y 0 N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m De Lara.Antonia.A. Unknown 1 rn `o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 99 0 p; DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑r uv 0 CIRCLE NUMBER(S) U1 Ncv ❑DV 1 9 6 9 Toyota RAV4 2024 00-NONE it 12..-_, DUE TO CRASH ❑ ® 98 73 o Yr 13-UNDER CARRIAGE 101 2 FIRE ❑ ® U2 C Ti M 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP 3 X 0 Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN *0istracton Value 0 H CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POFIRSNT OF T CONTACT 6 O7 ;�1.®1<�C•OM f esVEH SeeSidebar❑ ® Ut CO Z SOUTH ELGIN IL 60177 0 1 0 EQ84498 IL 2026 aR C M IL D 2T3A1 RFVXRC450113 Allmerica Financial Benef ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 10 = Enterprise FM Trust awcm011557 SAC 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) U2 996 r m ##occs y 71 / U1 1 D 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 09 105 i2025 07 02 ®PM in a Work Zone? ❑N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 2 0 28 41 N 3 0 0 CITATIONS ISSUED 0 PENDING + ) 0 PM• El Construction SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 7 -a, ARREST NAME / / El PM ' o N El 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility SLMT 45 t 2 0 ARREST NAME AM 7 1 r ❑❑PM El Unknown work zone type U1 n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 El ❑AM Workers present? 0 Y 45 1545-VanEycke. Brier 401 r { ❑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 truck trailer -< c ` --l- ' r 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 X <____ �____� NofToScale 3. isdesgnedtocarry15orfewerpassengersandoperatedbyacontractcarrier O } } } transporting employees In the course of their employment(example:employee X transporter-usually a van type vehicle or passenger car):or w L L.___------ 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including C } } for direct compensation(example:large van used for specificpurpose):or [he driver, j7i1 Pe ( P 9 Pe or O L l. i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D ® ® placarding(example:placards will be displayed on the vehicle). XI ® CARRIER NAME Z r+"' + ._ ADDRESS 0,a V) .t CITY/STATE/ZIP 0 0 MOTOR CARR.ID 0 Interstate ❑ 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 . Form Number m Xl IDOT PERMIT NO. WIDELOAD'; 0 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' -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 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 DUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE