HomeMy WebLinkAbout2025-00064354 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
I011011001 00111
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003'983273
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INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 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 3
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 202512025-00064354 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 mN STATE ST Elgin 12:50
® ❑ RELATED ®Y 0 N 10 01 2025 ❑AM YES ®NO U1 -<
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W TOLLGATE RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (/)❑ Kane HIT ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
® &RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑NW ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C)
0 4 /
yr l ! FIRE 0 (21
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED 0 0 U2 0 m
F 2 4 SYTM❑Y ®SNE❑UNK VEH. 0 AT CRASH 0 99-U 15-UNKNOWN THER9 16•TOP 3 *Distraction Value ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ ;i�a �i 4 COM VEH 0 Ea 1 0
~ East Dundee I L 6011$ B 1 0 FIRST CONTACT 2 7 : __5 *Irves.See Sidebar Ut
Z DX45437 IL 2026 E
TELEPHONE
IL D 1G N ERG KW2PJ279551 Nationwide ❑Y ®N U2 I'
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
co
Elgin Fire Same 9112J002092 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y El 2 0
m g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑row 0 Ncv ❑DV CIRCLE NUMBER(S) U1
/1 9 9 9 Mini Cooper 2019 00-NONE 11_"1 Qr O DUE TO CRASH 0 ❑ 2 x
0 13-UNDER CARRIAGE 10( I 2 FIRE 0 ® U2 C
c
M 2 4 SYSTEM IN 0 ENGAGED 15-OTHER 9 1,6-TOP 3 X
❑Y ON ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value U1 9
POINT OF s i1 �i 4 COM VEH ❑ ® CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR A 5
FIRST CONTACT 1 Y _, _5 •)ryes.See Sidebar
1= WEST DUNDEE IL 60118 C 1 0 DH65457 IL 2025 I 9 Sn
IL D 1 G N ERG KW2PJ279551 State Farm ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
Elgin Fire Same 2229204SFP13 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND O N U1 =
(UNIT) (SEAT) (DOBi (SEX) {SAFT) (AIR) (INJ) 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
2 3 05 /
:A
/ / UI 1 D
/ / 2 0
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 4 10/01 /2025 12 56 ®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)
2 0 36 1 2 28 10/O1 /2025 01 00 PM
® • 0 Construction *
R 3 ❑ Ei CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
z J ❑AM ❑Maintenance U2
-a, ARREST NAME JARVIS.AMAI RANI 11-902 W340000157 10/01 /2025 01 07 ®PM SLMT
1 ® ElUtilit 11 4 0 CITATIONS ISSUED SECTION CITATION NO. ROAD CLEARANCE TIME
PENDING
o Ny
T 2 ElARREST NAME 10/01 /2025 01 23 ®PM 0 Unknown work zone type U1 45
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 45
340-Phillips. Kathryn 500 / ❑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 —I
KUwo I N BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
r r r (example:shuttle or charter bus):or
IL
I
, 3. Is designed tocarry 15 fewer
pase and oer operated contract carrier O
L L. _A.._.� } } } transporting employeesn the cour their employmente :employee0
I transporter-usually a van type vehicle or passenger car):or w
L -----------I. '^ �" 1 - t I- t •4. Is used or designated to transport between 9 and 15 passengers,including the driver, C
== for direct compensation(example:large van used for specific purpose):or O
L L--_-a-.... � ' - L i. l I 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires M
uri .ir placarding(example:placards will be displayed on the vehicle). D
/ �� Z
CARRIER NAME Z
I ADDRESS D
ti rn
ONLY I 'i— i• ' i.' i.1 4.
' n
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate 0 Intrastate
I . ❑ Not in Comm./Govt. 0 Not in Comm./Other
; _Y_ _-1 - USDOT NO. ILCC NO. m
XI
Source of above z
. If Yes,Name on placard 0
4 digit UN NO. 1 digit Hazard class No. Xl
Xl
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z
own tank)? 0 Yes 0 No 0 Unknown
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' -n
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Black Black
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