HomeMy WebLinkAbout2025-00059914 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets II� III HH II11I1 1OUI
01100
11111 III II il 11111
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XO03969859`
u, 9 u21 1 1 1 u, 1 U2 1 U199 1_12 1 U1 99 U2 1 5 7 U1 99 U2 1 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY El g500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00059914 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m
BOWES RD El 07:54
® ❑ RELATED ❑Y ®N 09 11 2025 ❑AM ❑YES ®NO U1 -<
_ _ g PRIVATE mo I day I yr ®PM FLOW CONDITION m
FT l MI N E S W NOLAN RD COUNTY PROPERTY ❑Y 21N DOORING Ely #OF MOTOR 0 SLOW 15 u)
❑ Cook HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
0 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEOAL ❑EDUES N NW ❑ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
/ / FOR DAMAGEDAREA(S) FROPtf TOWED U1 0
Abrador Retriever. Brown 00-NONE it.. 12 , DUE TO CRASH 0 ® E
NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE IE
10 ! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3
1 3 ❑Y 0 N ❑UNK VEH. AT CRASH 99-UNKNOWN Detraction Value ALGN 2
s 4 COM VEH 0 Ea
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _,I[6 !i,_ 1 00
0 1 0 FIRST CONTACT 99 7_; _5 *IIYes,SeeSidebar U1
REAR
2 Z ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1
UNK. 0 NIA ❑Y ®N U2 I'
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
99 9 Fitchie.Jeannette NIA 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER
99 0
x DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑NMV 0 Ncv ❑DV
1 9 5 0 Honda CRV 2015 00-NONE O Qi-O DUE TO CRASH ❑ (� 2
0 13-UNDER CARRIAGE 19( I 2 FIRE ❑ ® U2 C
c
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s-it 6 1:,-4 COMVEH ❑ ® U1 CO
FIRST CONTACT 12 7�� _, .5 •If Yes.See Sidebar
= SOUTH ELGIN IL 60177 0 1 0 IM42YL FL 2010 0
IL D 0 3CZRM3H38FG714226 GEICO ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 4471-08-34109170 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
E/ MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 15 1 Fitchie.Jeannette. D. Unit 1-abrador retriever 09,11 ,2025 07 54 ®AM in a Work Zone? ®N DIRP co
I I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 99
T PROPERTY OWNERS ADDRESS:STREET.CITY,STATE,ZIP ❑AM U1 0
Eri 2 38W512 ARROWMAKER PASgLGIN IL 60124 21 99 09,11 ,2025 07 54 PM
,
® • ❑Construction *
Z 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM ❑Maintenance U2
-a, u ARREST NAME / / El PM '
1 ® 20 4 0 CITATIONS ISSUED ❑PENDING UtilitySLMT
SECTION CITATION NO. ROAD CLEARANCE TIME
o El
®AM U1
r 2 0 ARREST NAME 091 1 1 ,2025 08 10 PM ElUnknown work zone type
10
2 2 3 0 OFFICER ID SIGNATURE BEAT I DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 50
1527-Juarez.Jorge 801 391-Jacobucci 10 ,28,2025 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.
r ----r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
c ` --I -' r INDICATE NORTH combination):or .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
Si - } (example:shuttle or charter bus):or
X
. 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
——
__ __ _7 transporter-usually a van type vehicle or passenger car):or L L.___a__ it
1- m.41.1 } }} 4. Is used or designated to transport between 9 and 15 passengers,including the driver. C
1 for direct compensation(example:large van used for specific purpose):or
71
i. 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
a placarding(example:placards will be displayed on the vehicle). XI
.131 CARRIER NAME Z
1 ADDRESS
w
'""nSea,I CITY/STATE/ZIP 0
g
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other
;_...Y. ._.; - USDOT NO. ILCC NO. m
XI
Source of above z
IDOT PERMIT NO. WIDELOAD-; ❑Yes 0 No =
TRAILER VIM 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
Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 9 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