HomeMy WebLinkAbout2025-00062186 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 11111111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X0039684.98
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 7
VEHICLE/PROPERTY ®OVER$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and f or Tow Due To Crash YR 202512025-00062186 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 '1
15 LONGWOOD PL Elgin08:39
® ❑ RELATED 0 Y ®N 09 22 2025 ®AM ❑YES El NO U1 —<
_ g PRIVATE mo /day/yr ❑PM FLOW CONDITION MCOUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ FT!MI N E S W Kane 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
Q83 DRIVER I] PARKED I]DRIVERLESS 0 PED 0 PEOAL 0 EDUES 0 NIA/ 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C)
0 3 !
yr Chevrolet Express2006 00-NONE DUE TO CRASH ❑11-_ 12 - EN
13-UNDER CARRIAGE 10l 2 FIRE 0 NI
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 0 m
M 2 SY 15-OTHER
4 ❑Y ®SNE❑UNK VEH. 0 AT CRASIN H 0 99-UNKNOWN 9 76•TOP 3 `Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 7 i! 6 i.r.4 COM VEH 0 0 1 C)
~ ELGIN I N I L 60123 0 1 0 FIRST CONTACT 5 7 :,---1'O •II Yes.See Sidebar U1 0
Z 537559D IL 2026 REAR
TELEPHONE
IL D 1 G BJG31 U761225252 Progressive Ely igi N U2 m
5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
co
Same 992117279 1 1-
5 HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER en
Refused ❑Y El 2 0
0 DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 m/v 0 KCV 0 Dv
yr 1(I t2 _1 C
13-UNDER CARRIAGE 10 1 c 2 FIRE ❑ !� 2❑ U2 C
c ®70 SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ SPDR C)
SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 0 X
a ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN O `0istractlon Value
POINT OF 8 ) 4 Ut
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR _ S COM VEH 0 ® CO
F,,, FIRST CONTACT 6 Y t_,-`-®•If yes.See Sidebar C
FL54380 IL 2026 REAR 0 Si)
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
1 C4PJ M LB3KD309070 Safeway Insurance Company ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
Jimenez Santiz.Sonia.W. 4261443-IL-PP-001 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) tSEATI (008) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
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 09,22 /2025 08 39 ®❑pM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
97 2 ❑ 30 99
N 1 3 0 0 CITATIONS ISSUED 0 PENDING / 1 ❑PM El Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 7
—a, ARREST NAME / / El PM '
o N ® 11 5 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT
10
T 2 ARREST NAME AM
7 1 r ❑❑pM El Unknown work zone type U1
El
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ ❑AM Workers present? ❑Y 1 O
1547-Steele.Justin 501 397-Jones / / ❑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 Not
A CMV is defined as any motor vehicle used to transport passengers or property and: Z
I trots To Scale 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
} i•-- --:-- ' N } INDICATE NORTH combination):or -I
15 7PI i BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
�� } (example:shuttle or charter bus):or
X
L A 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
/ transporter-usually a van type vehicle or passenger car):or w
L rf 4. Is used or designated to transport between 9 and 15 passengers,includingy
---- ----; - } } g po the driver,
for direct compensation(example:large van used for specific purpose):or O
L i L i i. 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires ''El
placarding(example:placards will be displayed on the vehicle). m
0
_ D
- (*\t CARRIER NAME Z
ADDRESS 0
(Ofli>:I!
s— CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate ❑ Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
i- --- --1 - USDOT NO. ILCC NO. m
XI
Source of above z
.
Were HAZMAT placards on vehicle? 0 Yes 0 No =
If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. XI
XI
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 ❑ No 0 Unknown g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash?El❑ Yes II No 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 White
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: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE