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HomeMy WebLinkAbout2025-00058851 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets _ 01111101111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003951370 u, 1 U21 1 1 1 U199 U299 U, 1 1_12 1 U, 1 U2 99 1 17 U123 U223 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ❑$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 7 VEHICLE/PROPERTY ❑OVER$1,500 ®NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00058851 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I ® ❑ RELATED 0 Y ®N 09 07 2025 ❑AM ❑YES ®NO U1 -< 3 CLOCKTOWER PL Elgin PRIVATE mo /day/yr 01:00 ®PM FLOW CONDITION ITT 020 4C7!MI N E s © ClockTower PI.and National St. COUNTY PROPERTY ®Y El'COUNTY DOORING ❑Y #OF MOTOR 0 SLOW 15 u) Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I 0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0 (i DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 uuv 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0 0 9 / yr 13-UNDER CARRIAGE IE 10 !!. 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 U2 0❑ rr1 F 2 4 Y SYSTEM IN ENGAGED 15-OTHER 9 t6.TOP 3 9 ALGN = ❑ ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value r COM VEH 0 )g! 1 C) CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s l 6 ii,4 ~ ELGIN I L 60120 0 1 FIRST CONTACT 7 tz_; __5 *II Yes.See Sidebar U1 0 Z EV93540 IL ' E TELEPHONE IL D 2FMPK4J96RBA74981 State Farm ❑Y Igl N U2 13 . m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same 3418385SFP13 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER 73 Refused ❑Y ❑ N 2 0 m g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED 0 PEDAL 0 EWES O new 0 i v 0 Dv !1 9 y 7 8 Jeep(after 196g)ind Cherokee 2021 00-NONE 1 t2 (,�2 FIRE DUE O CRASH 0 ® U2 2 C o 13-UNDER CARRIAGE c M 2 4 SYSTEM IN ENGAGED 15-OTHER 9:1,6•TOP 3 9 0 X ❑Y ❑N DUNK VEH. AT CRASH 99-UNKNOWN *Distraction Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 - 6 il;, 4 COM VEH D ® tit W FIRST CONTACT 7 Q: -5 •If Yes.See Sidebar ELGIN IL 60120 0 1 EU35213 IL REAR C 0 cn IL D 1C4RJFAG2MC612921 State Farm ❑Y ®N RDEF 7) EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Villagran.Concepcion 20881858SFP13 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP 996 < Refused RESPOND 0 N U1 = (UNIT) (SEAT) (D081 (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 2 3 12 / 2 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 11 5 09,07 ,2025 01 21 ®AM 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 ❑ 18 18 N 3 ❑ ❑CITATIONS ISSUED 0 PENDING + ❑PM• ❑Construction SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM ❑Maintenance U2 -a, ARREST NAME / / ❑PM ' o N ® 11 5 • 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility SLMT r 2 ARREST NAME AM 7 1 r ❑❑PM ❑Unknown work zone type U El n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ - ❑AM Workers present? ❑Y 10 547 Homeier.William 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. A CMV is defined asmotor vehicle used to transportand: r ----,5-••--, ; any passengers or property Z 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< } i.-- -i-- --; } } } i- -, , ; ; , 1, ( INDICATE NORTH combination):or —I p1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } L ii , } (example:shuttle or charter bus):or x 3. Is . L.__-A_. 1 i. ..._... .___� J transporting edmployeeslIn5 hecourseeo theire rsmployment example:employeener X } } } transporter-usually a van type vehicle or passenger car):or co L <.__-a-_-_- , < <--_-a-___� 1 , , , 4. Is used ordesi nated to trans rt between 9 and 15 passengers,including C} } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or 0 L L___-a_ L L ...._-.�_ ; l. i i L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example:placards will be displayed on the vehicle). XI CARRIER NAME Z ADDRESS , n CITY/STATE/ZIP MOTOR CARR.ID 0 Interstate ❑ Intrastate 0 ❑ Not in Comm./Govt. ❑ Not in Comm./Other 0 -Y- --, ,--- -Y- ; ; ; : USDOT NO. ILCC NO. m XI Source of above z . Form Number m Xl IDOT PERMIT NO. WIDELOAD? ❑Yes 0 No 2 TRAILER VIN 1 m 'LOCAL USE ONLY TRAILER VIN 2 m a 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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE