HomeMy WebLinkAbout2025-00060903 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003963528
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S 1215501-51.500 ®ON SCENE 1
VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
El AMENDED
YR 202512025-00060903 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED PRIVATE ❑Y ®N 09 16 2025 ❑AM ❑YES ®NO U1
DUNDEE AVE Elgin mo /day/yr 04 28 ®PM FLOW CONDITION m
�O 1C.'J!MI O E S W Kimball St COUNTY PROPERTY ❑Y 21 N DOORING ❑y #OF MOTOR ❑SLOW 20 (n
Kane HIT&RUN ❑V ® N WITH VEHICLESOT,
INVLD DO
STOPPED U2 -I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
0 4 /
yr 13-UNDER CARRIAGE 10 ! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 4 rn
M 2 SY4 ❑Y ON E DUNK VEH. O AT CRASH M IN D O 99-UNKNOWN 9 16•TOP 3 `Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ it a �i 4 COM VEH 0 Ea 1~ ELGIN IL 60120 0 1 0 FIRST CONTACT 2 7 . - 0
_5 *Ir Yes.See Sidebar Ut 2
Isui
2 Z
TELEPHONE
IL B 7 State Farm ❑Y igi N U2 31 , m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
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Same 1590588 SFP 13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF`Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 0
❑ DRIVER ❑ PARKED 0 DRIVERLESS 0 PED N PEDAL 0 EWES 0 NMv 0 Ncv 0 DV CIRCLE NUMBER(S) U1
'1 9 9 2 Unknown Unknown 2023 00-NONE 1("i Qj O DUETOCRASH ❑ (� 2
0 13-UNDER CARRIAGE 10 I I., E FIRE 0 ® U2 C
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M 5 3 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOPO3 * X
❑Y Ni N ❑UNK VEH. AT CRASH 99-UNKNOWN 0istraellon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S-il 6 I( 4 COM VEH ❑ ® U1 W
FIRST CONTACT 1 O Y .5 •I Yes.See Sidebar
ELGIN IL 60120 C 1 0 NONE Unknown 0 I 0 C
IL D NONE NONE ❑Y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Elgin Fire 1 47 5 Same NONE SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Provena St.Joseph RESPONDER U1 =
(UNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((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 ® 13 1 09,16 ,2025 04 28 0 AM in a Work Zone? ®N DIRP co
I I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
v 2 28 99 09,16 ,2025 04 28 ®PM 0 Construction
>F
R O 0 ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
3 ❑AM ❑Maintenance U2
ou ® 13 2 ARREST NAME Chavez. Roberto, H. 11-601 S1552000176 09,16,2025 04 33 ®pM SLMT
o N 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
0 AM
t 2 ElARREST NAME 09(16 ,2025 04 28 ®PM ElUnknown work zone type U1 30
2 2 3 El OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 0 AM Workers present? 0 Y 30
1552-Thompson,Ahmad Rashad 301 10 ,21 ,2025 01 30 ®PM ®N U2
REMEMBER TO USE BLACK INK,PRESS HARD,PRINT LEGIBLY AND COMPLETE ALL REQUIRED FIELDS!
A Diagram and Narrative are required on all Type B crashes, LARGE TRUCK, BUS, OR HM VEHICLE
even if units have been moved prior to officer's arrival.
IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A
ADDITIONAL UNITS FORMS.
/ ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
r -- r.•--, , ///1/
I I 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
` ` --I -' I I INDICATE NORTH combination):or —I
f I is BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
1 -i - } (example:shuttle or charter bus):or
r r r
L --I--
A I 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
/ } } } transporting employees in the course of their employment(example:employee X
Itransporter-usually a van type vehicle or passenger car):or wL 1 } 4. Is used or desi nated to trans rt between 9 and 15 ge ng w---- ----; - } } g po passen rs,includi [he driver,for direct compensation(example:large van used for specific purpose):orL ----$----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
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CARRIER NAME Z
ADDRESS
Sr
C)
CITY/STATE/ZIP g
I I _ MOTOR CARR.ID 0 Interstate 0 Intrastate 5
I I T I /11 I ❑ Not in Comm./Govt. ❑ Not in Comm./Other 00
‘I. - --1 I USDOT NO. ILCC NO. m
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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
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
Black
U 'I 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: 3 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE