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HomeMy WebLinkAbout2025-00065593 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 011011001 OIl ll III III 111111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0039833O4 u, 9 U2 1 1 1 U1 99 U2 U199 U2 U,99 U2 1 1 9 U1 1 U221 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW ' Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00065593 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 mMAPLE LN Elgin ® ❑ RELATED ❑Y ®N 10 06 2025 ❑AM ❑YES ®NO U1 -< PRIVATE mo /day/yr 05:36 ®PM FLOW CONDITION m 0351C.'J!MI N E S © North JANE Dr COUNTY PROPERTY ❑Y ® N DOORING ❑Y #OF MOTOR IR SLOW 2 Cl) Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 -I 0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 18:DRIVER I] 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 02 n , FOR DAMAGEDAREA(S) FROPtf TOWED U1 Q Unknown.O. Unknown Unknown 00-NONE „ 12 , DUE TOCRASH ❑ EN NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 101 IE ! 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 02 m SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 9 9 ❑Y ID N DUNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN = s 4 COM VEH 0 Ea r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _,I[a !i,_ 1 0 ~ 0 9 FIRST CONTACT 99 7_; _5 *IIYes.See Sidebar U1 REAR 2 Z ' E TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 11/ NIA ❑Y ❑N U2 m 5' EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR co Same NIA 2 m `o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER r D Y°®N 0 5, 0 DRIVER I} PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 M/v 0 NCv 0 Dv yr 13-UNDER CARRIAGE 11 112 2 FIRE El El U2 C Ti SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED a SYSTEM IN 0 ENGAGED 0 15-OTHER 016•TOP 3 0 ® SPDR n ❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN *Oistrac on Value 9 U1 9 - POINT OF s ) -4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR!._ COM VEH D ® CO F„ FIRST CONTACT 11 7 , _5 •If Yes.See Sidebar V M B56-WS IL 2026 REAR 0 Si) M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 5Z62DOCT2CC433133 SAFECO ❑V ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Bennett.Vance. M. Z5421789 BAG $ 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) 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 18 1 10,06 �2025 05 36 ®pm 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 ❑ 30 28 N 3 ❑ ❑CITATIONS ISSUED 0 PENDING • + ) ❑PM• ❑Construction SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 7 -a ARREST NAME / / ❑PM ' o u ® 11 1 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility SIMT , 30 r 2 ❑ ARREST NAME AM 7 1 r ❑❑PM ❑Unknown work zone type U1 n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ ❑AM Workers present? ❑Y 30 1506-Nunez. Maria 602 - r / ❑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 -< r__--; CI combination):or INDICATE NORTH p0 Not To Scale BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C _ , _ } (example:shuttle or charter bus):or X L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O } } } transporting employees in the course of their employment(example:employee X transporter-usually a van type vehicle or passenger car):or w L ----------; f"- 't - • } } 1 4. Is used or designated to transport between 9 and 15 passengers,including the driver. y I I ` •' for direct compensation(example:large van used for specific purpose):or L L____A____; - o i i — - i. < i. 5. Is any vehicle used to transport any hazardous material(HAZMAT)thatrequires ,mil placarding(example:placards will be displayed on the vehicle). XI MgpLE?LN I CARRIER NAME —I ADDRESS Kg D rn CITY/STATE/ZIP g i • i.- i. i. i. MOTOR CARR.ID 0 Interstate ❑ Intrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other ----------1 - USDOT NO. ILCC NO. rn 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 v TRAILER WIDTH(S) 0-96" 97-102" >102' m TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z White 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: 3 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE