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HomeMy WebLinkAbout2025-00060057 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets II III H I I II 11111111111111110111111111111111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003953283 u, 1 U2 1 1 1 u, 9 U2 1 U113 u2 U, 1 U2 1 1 9 U123 u221 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El$501-$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 2025I 2025-00060057 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 m595 S STATE ST El 01:38 ® ❑ RELATED ❑Y ®N 09 12 2025 ❑AM ❑YES El NO U1 -< _ g PRIVATE mo !day!yr ®PM FLOW CONDITION m COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR 0 SLOW 15 u) ❑ FT/MI N E S W Kane 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 Q83 DRIVER O PARKED l]DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0 FOR DAMAGEDAREA(S) FROM© NT TOWED U1 Q nciso. Rosemary, D. 1 1 / yr 13-UNDER CARRIAGE 1 FIRE 0 IE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O 2 DISTRACTED 0 0U2 0 171 F 2 SYTM IN ENGAGEDTHER 4 ❑Y ®SNE❑UNK VEH. 0 AT CRASH 0 99-U15-UNKNOWN O9 16-TOP 3 `Distraction Value 9 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 0 i all } 4 COM VEH 0 0 1 n .V. Z West Chicago IL 60185 0 1 0 R650498 IL 2026 FIRST CONTACT 7 O7 -:�REAR -_6 *Yves.See Sidebar U10 c TELEPHONE IL D 0 3GYFNEE3XFS625951 Farmers ❑Y ®N U2 I' in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same 540330879 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER en Refused 0 Y El 2 0 ❑ DRIVER X. PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 NMV 0 NO! 0 Dv CIRCLE NUMBER(S) U1 yr 12 o 13-UNDER CARRIAGE 10 1 2 FIRE 0 ® U2 C c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR n SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP 3 9 0 a ❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN `0istractlon Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. ) 4 Ut STATE YEAR POINT OF 8 6 COM VEH ❑ 27 CO F,,, FIRST CONTACT 5 7 Iri •If Yes,See Sidebar C DE51995 IL 2026 REAR 0 N M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 JN8AT2MV1 LW113555 Allstate ❑Y ®N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Nava, Rafael 802015770 BAC $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)(TELEPHONE) (EMS) (HOSPITAL) W 01 / 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 18 5 09,12 l2025 01 38 ®AM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 4 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C) 2 ❑ 18 5 30 28 N 3 0 0 CITATIONS ISSUED 0 PENDING / ! ❑PM- ❑Construction SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 4 - N a, ARREST NAME / / ❑PM ' 1 ® 11 5 El Utility 0 CITATIONS ISSUED ❑PENDING SLMT S' SECTION CITATION NO. ROAD CLEARANCE TIME 0 AM T 2 0 ARREST NAME 09 r 1 2 12025 01 38 ®PM 0 Unknown work zone type U1 15 n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ 1542-Chase. Ethan 701 - 1 r ❑❑pM Workers present? ®N U2 15 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 0 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer - c ':--- -' -' 1 r INDICATE NORTH combination):or —I Not To Scale ; BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C - } (example:shuttle or charter bus):or X 1 1r l- <----a_---i it - - 3. Is designed to carry15 or fewer passengers and operated a contract carve , } } } transportingemployees In the course of their employment example:employee X j; transportr-usually a van type vehicle or passenger car):or L L.___a__...I. - 4. Is used ordesi natedtotrans rtbetween9and15passengers,includingthedriver. C 1 // t } } for direct compensation(example:large van used for speific purose):or N L L--_-a-___� ��;°'' t i. } } 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m placarding(example:placards will be displayed on the vehicle). ;p —1 CARRIER NAME Z ADDRESS 0 w C) CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate El Intrastate 0 1 I r 1 ,...,.r,. ❑ Not in Comm./Govt. 0 Not in Comm./Other i— --- --1 - USDOT NO. ILCC NO. m m XI Source of above z . • m Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z own tank)? 0 Yes 0 No 0 Unknown T. 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 to 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 White Silver 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/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE