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HomeMy WebLinkAbout2025-00061075 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 IIIIII DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003966736 u, 1 U21 2 4 1 U, 2 U2 1 U, 1 u2 1 U, 1 u2 1 1 10 U1 3 u2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 15 VEHICLE/PROPERTY El OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash El AMENDED YR 2025I 2025-00061075 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I ® ❑ RELATED ®Y 0 N 09 17 2025 ®AM ❑YES ®NO U1 N STATE ST Elgin11:59 _ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m FT!MI N E S W FRAZIER AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLESOT, INVLD ❑ STOPPED U2 --I CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EDUCE ❑uuv ❑!Cy ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0 0 1 / yr 13-UNDER CARRIAGE ©i - FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 2 DISTRACTED 0 0 U2 4 <<Tl M 2 SY8 ❑Y ONM❑UNK VEH. 0 AT CRASH IN 0 15-OTHER 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF it B �i COM VEH 0 Ea 4 0 ELGIN IL 60123 B 1 0 FIRST CONTACT 11 2:-; -__5 *Ilves.SeeSidebar U1 Z ET17663 IL 2026 REAR TELEPHONE IL D KM U MCDTC6N UO41686 American Family ❑Y ®N U2 13 , m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same 0945-5717-15 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER 73 > Refused ❑Y ElN 2 0 m N DRIVER ❑ PARKED ❑DRIVERLESS ❑ FED ❑PEDAL ❑EWES ❑ uv 0 NCv ❑DV yr Q 2 �1 0 13-UNDER CARRIAGE 10 j ©( 2 FIRE ❑ ® U2 C c M 2 8 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *OistractIon Value 9 POINT OF 8 i1�.,-4 COM VEH ❑ ® U1 W N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6 FIRST CONTACT 1 Y A _, _5 •• •IfYes,See Sidebar — Bolingbrook IL 60490 B 1 0 FC87260 IL 2026 I 9 C IL D 1 FMDE8BH5RLB26298 Progressive ❑Y ®N RDEF M EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 = Same 990154731 BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER u1 = (UNIT) (SEAT) (DOB) (SEX) {SART) (AIR) (INJ) (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 ❑Y U2 Z N 1 ® 11 1 09,17 l2025 11 59 ®❑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 � 0 2 ❑ 23 15 , ) ❑PM ❑Construction * Z 3 ❑ xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 o1 ® 11 1 ARREST NAME Vargas.Jovani. R. 11-1204-B 340000153 / ! ❑PM SLMT o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility 35 r 2 ❑ ARREST NAME AM 7 1 r ❑❑PM ❑Unknown work zone type U1 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 35 340-Phillips. Kathryn 500 10 , 14,2025 09 00 ❑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 (r ADDITIONAL UNITS FORMS. r ----r•---, , 1 N 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 combination):or i INDICATE NORTH Not 7b Scale I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } 117 } (example:shuttle or charter bus):or 0 I S. I. 41 } } } designed tocarry 15 or fewer passengers and operated by a contract carrier I O }.___A....; Is etg transporting employees In the course of their employment(example:employee P.O.k A nit ti transporter-usually a van type vehicle or passenger car):or c0 C L L.__-a-_-_1 'Nj - } } } •4. Is used or designated to transport between 9 and 1passengers,includingthedriver, for direct compensation(example:large van used fors specific purose):or L L____a..... rR.,CICR?A'.0 < < t 5 Is an anyvehdeused to transport hazardous material(HAZMAT)that requires I IIIILIII placarding(example:placards will be isplayed on the vehicle). XI I CARRIER NAME Z ism! O '� I ADDRESS D PARK:N(57LO'. I CITY/STATE/ZIP g ENTRANCa C II I I MOTOR CARR.ID 0 Interstate ❑ Intrastate 1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other ---"-1 - USDOT NO. ILCC NO. m XI Source of above z . 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 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 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 White Gray u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT' 3 TOWED BY/TO. Redmons/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 ® Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE