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HomeMy WebLinkAbout2025-00064370 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II III HH II11II OUI 0011000011th I HHIIOOHHI 100 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0039.82463 u, 1 U21 1 1 1 U116 U2 1 U, 1 u2 U, 1 U2 1 1 9 U1 1 U221 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW ' Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 7 VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT) 0 AMENDED ® B Injury and/or Tow Due To Crash YR 202512025-00064370 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 m1725 N STATE ST EIin ® ❑ RELATED ❑Y ®N 10 01 2025 02:21 ❑AM ❑YES ®NO U1 -< _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR 0 SLOW 10 fA ❑ FT/MI NESW Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 g DRIVER t] PARKED O DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 NIAV 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0 0 5 / yr 13-UNDER CARRIAGE ©i 4 O FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O O DISTRACTED ® 0 U2 0 m M 2 4 ❑Y ®SYSNEM❑UNK VINEH. 0 AET CRASH 0 99-UUNKNOWN THER 9 16•TOP�3 *Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 7 iL a 4 COM VEH 0 El 1 0 ~ ELGIN I L 60123 0 1 0 FIRST CONTACT 12 7_: _5 *lI ves.See Sidebar U1 Z AC73106 IL 2025 REAR TELEPHONE IL D 0 SFNRL5H60BB074351 Allstate ®Y ❑N U2 m IF. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Elgin Fire 99 9 Same 811175730 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Sherman ❑Y El 2 0 rg- a DRIVER I} PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMV 0 NOV 0 DV yr Honda CBR1000RR 2025 00-NONE 11_ •Oi'-_, DUE TO CRASH ❑ 2 �7 o 13-UNDERCARRIAGE I. FIRE 0 ® U2 C c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O O DISTRACTED a SYSTEM IN 0 ENGAGED 0 15-OTHER 9 6 TOP®* 0 ® SPDR ❑Y ®N DUNK VEH. AT CRASH 99-UNKNOWN Distraction Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 0 '1�COM VEH ❑ ® U1 CO F,,, FIRST CONTACT 3 O7 1.Qi_.OS •((Yes,See Sidebar M CYG E240 IL 2025 aaR 0 M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 JH2RH2406SK000606 State Farm ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Deckard. Dean 13-31 E5-005 BAC $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI j(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 1 4 11 / / / UI 2 :A m / / 0 O EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2Z N 1 ® 18 S Alexanders Cafe NIB side of property 10,01 /2025 02 21 ®AM in a Work Zone? ®N DIRP co 1 1 PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C) 2 0 1725 N STATE ST ELGIN IL 60123 28 18 10,01 ,2025 02 21 pM , ® • 0 Construction * Z 3 0 ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM 0 Maintenance U2 a •7 ARREST NAME 1 0/01 /2025 02 25 ®pM ' 1 El 1 5 0 CITATIONS ISSUED ❑PENDING UtilitySLMT o NSECTION CITATION NO. ROAD CLEARANCE TIME El t 2 El ARREST NAME 10/01 /2025 03 30 0 PM 0 Unknown work zone type U1 0 AM 15 n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ 1548-Crandall. Matthew 501 ❑AM Workers present? ❑N 15 / / ❑PM ® 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 0 ADDITIONAL UNITS FORMS. r ----r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z Not To Scare I 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -< c ` --I -' r INDICATE NORTH combination):or —I Thiel'EDrla BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C b - (example:shuttle or charter bus):or 0 X - ------;----; transportingtlgem lloyeeo sl5 or fewer in the course of passengers e ersnandoyment example:employee a contract t F p employment'Mid I I�1 I I transporter-usually a van type vehicle or passenger car):or II------ll------II------InI��'I��ti III -- -- - } } 1 •4. Is used or designated to transport between 9 and 15 passengers,including the driver. N for direct compensation(example:large van used for specific purpose):or L L__ _a____J . 4 _ t i. i ._ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 71 placarding(example:placards will be displayed on the vehicle). m lid -1 CARRIER NAME —I U ADDRESS Ili sIn 4 CITY/STATE/ZIP i. i. i. !' �' - MOTOR CARR.ID 0 Interstate 0 Intrastate ❑ Not in Comm./Govt. ❑ Not in Comm./Other 0 ----------1 Alexander's - USDOT NO. ILCC NO. C Cafes Xl 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? 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' T TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Gray Blue.Light u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. Arties/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE