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HomeMy WebLinkAbout2025-00064988 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111 011011001 OIl III 1 UI111110 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0G3'983237' u, 9 U2 1 1 1 U1 99 U2 U199 1_12 U,99 U2 1 5 9 u, 1 U221 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and for Tow Due To Crash YR 2025I 2025-00064988 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 FI ENTERPRISE ST Elgin ® ❑ RELATED ❑Y ®N 10 03 2025Ilk. ❑YES El NO U1 —< PRIVATE mo /day/yr 08:42 ®PM FLOW CONDITION m 15(� COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 15 u) ® C.7!MI N E s © HILL Ave WITH VEHICLESOT, INVLD ❑ STOPPED U2 --I O AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN I2J Y ❑ N PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 18:DRIVER p PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n yr 13-UNDER CARRIAGE IE f� !!. 2 FIRE El STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED U2 2 < 9 9 SYSTEM IN 9 ENGAGED 9 15-OTHER 9 16.TOP 3 ❑ _ ❑Y ❑N ®UNK VEH. AT CRASH ®-UNKNOWN `Distraction Value 9 ALGN s 4 COM VEH ❑ j$J r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _,Il 6 �i._ 1 0 ~ 0 9 0 FIRST CONTACT 2 7_ 11 _5 *II Yes.See Sidebar Ut Ismi 2 Z ' E TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 11/ NONE El ®N U2 m .5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same NONE 1 rn `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused 0 Y ® N 99 0 ❑ DRIVER X. PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 N4y 0 i CIRCLE NUMBER(S) U1 v 0 DV yr 13-UNDER CARRIAGE 11�( t2 2 FIRE 0 El U2 C Ti SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O' DISTRACTED 0 ® SPDR n SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 9 a 0 Y ❑N 0 UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value POINT OF 8 it . -4 Ut N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 1 O TA=--It5 •COM Sidebar❑ ® CO H BZ24649 I L 2026 REAR9 N M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 1J4RR5GGXBC528296 STATE FARM ❑Y 123 N RDEF X EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 LOPEZ. MARIA UNKNOWN BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = )UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 18 9 10,03 i2025 08 42 ®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 2 0 18 18 N 3 0 0 CITATIONS ISSUED 0 PENDING + ) 0 PM• 0 Construction SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 7 z —a ARREST NAME / / ❑PM ' 1 ® 1 1 1 ❑CITATIONS ISSUED ❑PENDING Utility SLMT , o u SECTION CITATION NO. ROAD CLEARANCE TIME 0 y 0 AM r 2 0 ARREST NAME 10+03 r2025 08 42 ®PM 0 Unknown work zone type U1 30 n T OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 — ❑AM Workers present? ❑Y 30 433 Miracle. Matthew 201 , ❑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 -< c ` '' -' r INDICATE NORTH combination):or —I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C j. - } (example:shuttle or charter bus):or X < ----- -•-•; Iltil transporting mployeeslin 5 he courses passengersr hir employd ment example:employee transporter or X co i. `' ' Not TO Scale _ ` Oar s uosed or des g nated to translly a van type port betweeicle or n 9 and 15 enger passengers,ssen rs,including the driver, I } for direct compensation(example:large van used for specific purpose):or L i L i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D placarding(example:placards will be displayed on the vehicle). m,Zt : CARRIER NAME Z v., _ ADDRESS 0 I CITY/STATE/ZIP n MOTOR CARR.ID 0 Interstate El Intrastate I r ❑ Not in Comm./Govt. 0 Not in Comm./Other ----------- - USDOT NO. ILCC NO. rn 73 Source of above z . If Yes,Name on placard O 4 digit UN NO. 1 digit Hazard class No. P3 XI 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 M D Did Carrier Safety Regulations MCS)violation contribute to the crash? A ❑ Yes II No 0 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 VIM 1 m co LOCAL USE ONLY TRAILER VIN 2 m v TRAILER WIDTH(S) 0-96" 97-102" >102' m TRAILER 1 0 0 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z 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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE