HomeMy WebLinkAbout2025-00065789 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
011011001 I 1 III
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003984968
u, 9 U21 3 4 2 U110 U2 1 U,99 1_12 1 U,99 U2 1 4 11 U1 2 U2 1 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY El$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 2
VEHICLE/PROPERTY ❑OVER$1,500 ®NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and for Tow Due To Crash YR 2025I 2025-00065789 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 71
® ❑ RELATED ❑Y ®N 10 07 2025 ®AM ❑YES ®NO U1
SHALES PKWY Elgin 06:30
_ g PRIVATE mo !day!yr ❑PM FLOW CONDITION m
FT!MI N E S W RT20 COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ Cook HIT&RUN ®Y ❑ N WITH VEHICLES INVLD ❑ STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV ❑ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
/ / FOR DAMAGEDAREA(S) FROPtf TOWED U1 0
Unknown.O. Unknown Unknown 00-NONE „ 12 , DUE TOCRASH ❑ VI
NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 101 ! 2 FIRE 0 M <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ ]$I U2 m
SYSTEM IN ENGAGED 15-OTHER 9 le-TOP 3
9 9 ❑Y ❑N DUNK VEH. AT CRASH ®-UNKNOWN `Distraction Value 9 ALGN =
$ 4 COM VEH ❑ j$J
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _,I[S !i,_ 1 00
I— 0 9 9 FIRST CONTACT 99 7_; _5 *II Yes.See&debar U1
REAR
2 Z ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1/
unknown ❑Y ❑N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
to
Same unknown 2 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 99 0
m g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑NOV 0 KCv ❑DV
!1 9 yf 4 Buick Envista 2025 00-NONE ,t_' t2.._, DUETO CRASH ❑ 2 x
0 13-UNDER CARRIAGE 101 2 FIRE ❑ El U2 C
c
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 016•TOP 3
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value 9
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF O I !,_4 COM VEH ❑ ® U1 COF,,, FIRST CONTACT 9 7 _, _5 •If Yes.See Sidebar C
E LG I N IL 60123 0 1 0 CB80050 IL 2026 REAR0 Si)
M
IL D KL47LAEP5SB159857 Progressive Insurance ❑Y ®N RDEF P3
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 986739308 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER®N u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 10,07 l2025 02 54 ®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
57 2 ❑ 04 99
N 3 ❑ 0 CITATIONS ISSUED 0 PENDING + ! ❑PM• El Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 3
z
—a, ARREST NAME ! ! El PM '
o u ® 11 5 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
SLMT
45
ARRESTNAME AM
Tr 2 ❑ ❑❑PM ❑Unknown work zone type U1
1 1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 El ❑AM Workers present? ❑Y 45
562-Hernaindez. Myra - r 1 ❑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.
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rr -r- , , A CMV is defined as any motor vehicle used to transport passengers or property and: Z 1. Hasa weight rating more than 10,000 pounds(example:truck or truck trailer -<
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INDICATE NORTH comWrtation)or BYARROW2Isusedordesigned to transport more than 15 passengers including the driver 1"-„''� - } (example:shuttle or charter bus):or X
i_ r rf�•+o mka; 3. Is ds ned to 15 or fewer
` g carry passengers and operated by a contract career i O
}----- ----; - } } } transportingemployees In the course of their employment
icle or
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< ...I. - ---- ftstib - 1 1 4.transporter
�sedordsinatedtotransportbetween9and15)(seeers,includingthedriver,
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———- } for direct compensation(examp large van used for specific purpose):or
L L..._a____. `.>>,,' - l. L I 5. Is anyvehicle used to transport any hazardous material(HAZMAT)that requires 'D
-„a u"'' ———_ placarding(example:placards will be displayed on the vehicle). XI
' 1 CARRIER NAME Z
1 Z) 1
ADDRESS 0( D
CITY/STATE/ZIP n
/ i. i. i. i. 4. MOTOR CARR.ID 0 Interstate 0 Intrastate
I / ❑ Not in Comm./Govt. ❑ Not in Comm./Other
0
;_...Y. ._' / i. USDOT NO. ILCC NO. C
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Source of above z
. Form Number
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IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
a
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
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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE