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HomeMy WebLinkAbout2025-00061019 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 011011001 0111101 1110 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003969827 u, 1 U21 1 1 1 U1 7 U2 1 U, 1 1_12 1 U1 1 U2 1 1 11 U1 1 U2 1 *P 0 1 1 9* INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT El 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$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash 0 AMENDED YR 2025I 2025-00061019 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 mSUMMIT ST Elgin 07:41 ® ❑ RELATED ❑Y ®N 09 17 2025 ®AM El YES ®NO U1 -< g PRIVATE mo !day!yr ❑PM FLOW CONDITION m 0 !MI N E s ShadyOaks Dr and Summit St COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 2 Cl) © Cook HIT&RUN ❑V ® N WITH VEHICLESOT, INVLD DO U2 —I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 (i DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 KIN 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n 0 3 ! yr 13-UNDER CARRIAGE 10.I 2• FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 2 m F 2 4 n 15-OTHER ❑Y ®N SYSTEM VEH. AT CRASH 99-UNKNOWN 9 16•TOP 3 `Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF & i�S 4 COM VEH ❑ j$J 1 O F. Palatine IL 60074 0 1 0 FIRST CONTACT 12 7 . _5 *IIYes.SeeSidebar U1 Z DU78715 IL 2025 E TELEPHONE IL D 0 5N1AR18B09C617900 Kemper 0Y ® 4 U2 I- 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same 12RA000053922 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER XI Refused ❑Y ® N 2 0 N DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑ o v 0 KKv ❑DV $ !1 9 9 8 Toyota Tundra 2023 00-NONE 'o,1 t2 c,�2 DUE O CRASH 0 ® U2 2 C o 13-UNDER CARRIAGE Ti M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istracton Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S 1 S .t. 4 COM VEH D ® Ut CO FIRST CONTACT 6 O7 ,�=Q)OS •If Yes.See Sidebar C Z SOUTH ELG I N IL 60177 0 1 0 3510808B IL 2026aR 0 N n IL B 0 STFLASDBXPX081481 Progressive ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Same 967144071 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 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 11 1 09,17 l2025 07 41 Am 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 C) 0 2 ❑ 03 99 ) ! 0 PM ❑Construction * Z3 0 1!>I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 o1 ® 11 1 ARREST NAME Borunda.Antonia 11-710-A W1557000096 ! ! El Pm SLMT o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility 40 T 2 ARREST NAME AM 7 1 r ❑❑PM ❑Unknown work zone type U1 El OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 - ❑AM Workers present? ❑Y 40 1557-Wieske. Nathan 201 , ! El 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 truck trailer -< ` ` --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 - } (example:shuttle or charter bus):or X L A ® } 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O } } transporting employees in the course of their employment(example:employee transporter-usually a van type vehicle or passenger car):or CO L L.___a _ I I I u°r A } } } •4. Is used or designated to transport between 9 and 15passengers,including the driver. C JI` acwI.I for direct compensation(example:large van used fors cific purose):or to L t l. I I 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m urnr — placarding(example:placards will be displayed on the vehicle). ;p r I r surmmest - D I CARRIER NAME Z I sn.ey.r. ADDRESS 0 C) CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate 0 Intrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other -"---- --1 - USDOT NO. ILCC NO. rn 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? ❑ Yes II No ElUnknown A 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' m TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Silver Blue u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. _Other/Unknown . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO: DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE