HomeMy WebLinkAbout2025-00064452 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0039833 3
u, 9 U21 1 1 1 U199 U299 U199 1_12 1 U,99 U2 99 3 1 U1 1 U299 *P 0119*
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 El$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY El OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 2025512025-00064452 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m
® ❑ RELATED ❑Y ®N 10 01 2025 ❑AM ❑YES ®
PRIVATE NO U1
W HIGHLAND AVE Elgin mo /day/yr 07.10 ®PM FLOW CONDITION m
02040 O COUNTY PROPERTY El'COUNTY ® N DOORING El #OF MOTOR 0 SLOW 99 Cl)
!MI N S W Madison Ln WITH VEHICLES INVLD ❑ STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN I2J Y ElN PEDALCYCLIST IZI N ® 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 02 0
NAME(LAST,FIRST,M) mo
yr 13-UNDER CARRIAGE .I FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 1U 'O 0 0 02 m DISTRACTEDU2
9 9 ❑Y SYSTEM IN 9 ENGAGED 9 15-OTHER 9 16.TOP 3 _
❑N ®UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 9 ALGN
s 4 COM VEH 0 El r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _,1[a !i,_ 1 0
~ 0 9 9 FIRST CONTACT 2 7_; _5 *II Yes.See&debar Ut
REAR
2 Z ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 11/
nla ❑Y ❑N U2 m
5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
co
99 9 Same nla 1 I-
`o HOSPITAL(TAKEN TO) INCIDENT IF`Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER en
Refused ❑Y ® N 99 0
0 DRIVER 0 PARKED 0 DRIVERLESS N PED 0 PEDAL 0 ewes 0 NMV 0 NOV 0 DV
2 0 0 9 Unknown Unknown 00-NONE 11_"j t2 -_, DUE TO CRASH ❑ ® 99
0ij 13-UNDER CARRIAGE 10'I 2 FIRE 0 ® U2 C
M 1 3 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distracion Value 9 9
POINT OF 8 i1�I" 4 COM VEH ❑ ® U1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 99 7J- .5 •IfYes,See Sidebar C
— Elgin IL 60124 0 1 0 Si)
0
D
D 0 ❑Y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
1 57 11 BAc $
HOSPITAL(TAKEN TO) INCIDENT RESPONDER IF'Y' OWNER STREET,CITY STATE,ZIP 996 ARefused ❑Y ®N U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 12 2 10,01 ,2025 07 10 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
57 2 ❑ 20 41
N 3 ❑ 0 CITATIONS ISSUED 0 PENDING + ) ❑PM• ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 7
— u a ARREST NAME / / ❑PM '
❑ 12 2 ElUtility
0 CITATIONS ISSUED ❑PENDING SLMT
o,
SECTION CITATION NO. ROAD CLEARANCE TIME 0 AM
t 2 ElARREST NAME 10 i 01 12025 07 30 0 PM ElUnknown work zone type U1 30
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 1561-Sarovic• Mirko 601 269-Mendiola , , ❑❑PM Workers present? ®N U2 30
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
` ` '
___ ___ ' Not To Scale
r INDICATE NORTH_ 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer
combination):or -<
p0
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i_ I - } (example:shuttle or charter bus):or 0
I j �
o N '� 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O
I- I- -A----1 i
} } } transporting employees in the course of their employment(example:employee � X
r transporter-usually a van type vehicle or passenger car):or w
L 4. Is used or designated to transport between 9 and 15 passengers,including C
�.___a____� • _ } } } g po passen rs,includi the driver,
for direct compensation(example:large van used for specific purpose):or O
5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
a _ placarding(example:placards will be displayed on the vehicle). 'D
m
XI
CARRIER NAME Z
ADDRESS 0
w
C)
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
; _Y_ _..; - 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'; 0 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
Gray
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: 9 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE