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HomeMy WebLinkAbout2025-00062517 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I011011001 011 III II II IIIIII DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003969B51 u, 1 U21 2 4 1 U, 2 U2 1 U, 1 U2 1 1.11 1 U2 1 1 10 Ui 3 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 15 VEHICLE/PROPERTY ❑OVER 51,500 ❑NOT ON SCENE(DESK REPORT) El AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00062517 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 m® ❑ RELATED ®Y 0 N 09 23 2025 ❑AM ❑YES ® PRIVATENO U1 BIG TIMBER RD Elgin mo /day/yr 02:49 ®PM FLOW CONDITION m ®05 FT/� N E s © North MCLEAN Blvd COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 Cl) Kane HIT&RUN ❑Y ® N WITH VEHICLESOT, INVLD DO STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 00 0 0 3 / yr 13-UNDER CARRIAGE ©i FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O " 2 DISTRACTED 0 0 U2 00 M M 2 SYTM IN ENGAGETHER 4 ❑Y ®SNE❑UNK VEH. 0 AT CRASH 0 99-U15-UNKNOWN 0 16-TOP 3 ,Distraction Value 9 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $,_iL a �i COM VEH 0 j$J 1 0 ELGIN IL 60123 0 1 FIRST CONTACT 11 7 ; __5 *Ilsees.SeeSidebar U1 Z 8560DD IL 2026 REAR TELEPHONE IL C 1 FTEW1 EF1 G FB51833 SafeCo ❑v ®N U2 m IS EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same Z5388511 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused El 23N 2 0 x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL ❑EWES 0 New 0 i v 0 Dv 9 9 5 Chevrolet Malibu 2015 00-NONE 11_ NT"1 Qj O DUE TO CRASH ❑ 2 x yr 13-UNDER CARRIAGE I I! FIRE ❑ El U2 M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9I1,6-TOP 3 X ❑Y 10 N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistrac on Value 9 0 8 i1 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S L - COM VEH ❑ ® U1 to FIRST CONTACT 1 Y _, _5 • — Montgomery IL 60538 0 1 AT49323 IL 2026 REARIfYes,See Sidebar 0 N IL A 1 G 11 C5SL7FF135135 State Farm ❑Y ®N RDEF 7) EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Same 0721561-SFP-13 BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER ut = KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 1 0 EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 CD 10 4 09,23 /2025 02 49 AM®pm in a Work Zone? NJ DIRP D co 1 IT PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 5 n F.; 2 ❑ 2 99 + / ❑PM. ❑Construction * R 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 ❑AM ❑Maintenance U2 o ® 11 4 ARREST NAME Pompa. Brian. K. 11-902 1506-451 / ! El PM SLMT o N • ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility 35 r 2 ARREST NAME AM T El 1 ❑❑PM ❑Unknown work zone type U1 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 35 1506-Nunez. Maria 502 391-Jacobucci 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 ADDITIONAL UNITS FORMS. A CMV is defined asmotor vehicle used to transportand: r ----,5-••--, ; any passengers or property Z 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< } i.-- -i-- --; ; } } } i- -, , ; ; , ; ( INDICATE NORTH combination):or —I p1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } ' i 1 , } (example:shuttle or charter bus):or X 3. Is L L.___A_. 1 i. ..._... . J transporting edmployeeslIn5 hecourseeo theire rsmployment example:employeener X } } } transporter-usually a van type vehicle or passenger car):or 1:0 < <.__-a-_-_- , < <--_-a-___� . , , , 4. Is used ordesi nated to trans rt between 9 and 15 passengers,including C} } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or 0 L L___-a____.: L L L ...._-..i._ ; l. i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example:placards will be displayed on the vehicle). XI CARRIER NAME Z ADDRESS 0 , n CITY/STATE/ZIP MOTOR CARR.ID 0 Interstate ❑ Intrastate 0 ❑ Not in Comm./Govt. ❑ Not in Comm./Other 0 USDOT NO. ILCC NO. m XI Source of above z . 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 Red White u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 2 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/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE