HomeMy WebLinkAbout2025-00064110 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 011011001 11I1111lI1111 HI
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY El OVER$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 2025512025-00064110 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 f7
SUMMIT ST Elgin03:49
® ❑ RELATED ' V 0 N 09 30 2025 DAM ❑YES ®NO U1
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION MFTlMI N E S W DUNDEEAVE COUNTY PROPERTY El ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
/ / FOR DAMAGEDAREA(S) FROPtf TOWED U1 Q
Subaru XV Crosstrek 2.0 2016 00-NONE , DUE TO CRASH 0
NAME(LAST,FIRST,M) Unknown, Unknown.0. mo yr 't_ 1z
13-UNDERCARRIAGE l 2 EN E
FIRE ❑
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STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ]$I U2 4 <<Tl
SYSTEM IN ENGAGED 15-OTHER 9 76.TOP 3
F 9 9 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN $ 4 `Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _iII S ii COM VEH 0 )g! 1 0
~ 0 9 0 FIRST CONTACT 6 7_;LQ__5 *IrYes.See Sidebar U1
Z FH27773 IL 2025 mai
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 11/
JF2GPABC2GG256523 NIA ❑Y ❑N U2 I—
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
ID Same NIA 1 I-
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
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g DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 M/V 0 KCV ❑Dv CIRCLE NUMBER(S) U1
/1 9$7 Chevrolet Traverse 2015 00-NONE 'o,1 t2 (,-2 FIRE DUE O CRASH 0 ® U2 2 73
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0 Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN `0istrac on Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 1 S .I. 4 COM VEH ❑ MI Ut CO
FIRST CONTACT 6 O7 ,�=Q)OS •IfYes.SeeSidebar C
E LG I N I L 60120 0 1 0 DW55565 I L 2025 FIRST
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IL D 1 G N KVG KDSFJ 166415 Direct Auto ❑Y ®N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
Cabrera Raga,Alan PAI L001227186 BAC
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HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (D081 (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 09,30 /2025 03 49 ®pm in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
2 30 99
N 3 0 ❑CITATIONS ISSUED 0 PENDING + / ❑PM• El Construction
SECTION CITATION NO. ENS ARRIVED TIME 1
❑AM ❑Maintenance U2
—a, ARREST NAME / / ❑PM '
1 ® 11 1 ❑CITATIONS ISSUED PENDING SLMT
o u SECTION CITATION NO. ROAD CLEARANCE TIME
0
Utilit y
t 2 El ARREST NAME 09/30 /2025 03 50 ®PM El Unknown work zone type U1 40El AM
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ 1552-Thompson.Ahmad Rashad 102 269-Mendiola / / ❑❑pM Workers present? ®N U2 40
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
/ i
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} / } r r (example:shuttle or charter bus):or 0/ / 3. Is desgned to carry 15 or fewer passengers and operated by a contract carrier I O
I- <.__-A-.-.J / / - y } } } transportingemployees In the course of their employment
/ _ pbymar);or(example:employee w
/ — transporter-usually a van type vehicle or passenger car):or �
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i. }--- ----; - • } } } 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 O
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L .I. i i _ 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
-- - ram—"' placarding(example:placards will be isplayed on the vehicle). m
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/ CARRIER NAME
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� ADDRESS
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._ � CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
I . ❑ Not in Comm./Govt. 0 Not in Comm./Other
; _Y_ _..; - USDOT NO. ILCC NO. m
XI
Source of above z
. If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. Xl
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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
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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
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Form Number 0
m
Xl
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
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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 Red
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: 1 TOWED BY/T0
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE