HomeMy WebLinkAbout2025-00065557 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 011011001 OIl 0111 1110
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00393593
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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 El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and f or Tow Due To Crash YR 202512025-00065557 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 71
LARKIN AVE Elgin03:05
® ❑ RELATED ❑Y ®N 10 06 2025 ❑AM ❑YES El NO U1 -<
_ _ PRIVATE mo !day/yr ®PM FLOW CONDITION M FT/MI N E $ W N WORTH AVE COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 1 cn
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 1 C)
EN
0Lafrance.Olivia. R. Dodge Caravan(inc Grand)2016 00-NONE Q �i 7T OUETOCRASH ❑
NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 10.I 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL)THERDISTRACTED ® 0 U2 1 M
F 2 4 SYTM❑Y 0$NE DUNK VEH. 0 AT CRASH 0 15-99-UUNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN
-
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, it 6li 4 COM VEH 0 ZgJ 1 0
~ ELGIN I L 60120 0 1 0 FIRST CONTACT 12 7_;1 _5 *elves.See Sidebar U1
ZFD11504 IL 2026 E
M TELEPHONE
IL D 0 2C4RDGBG4GR139109 Progressive ❑Y IlN U2 I'
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 993089521 2 r
`o HOSPITAL •
(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER •
RESPONDER >
Refused 0 Y ® N 2
m g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES O NW 0 i v ❑Dv
!2 0 0 8 Honda Accord 2004 00-NONE ,t"i 12..-_, DUE TO CRASH 0 C 2
o - 13-UNDER CARRIAGE 10} 2 FIRE ❑ ® U2 C
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3
❑Y ®N DUNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 U1 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 i 6 I,, 4 COM VEH ❑ ® W
I� FIRST CONTACT 6 O7 ,.0:-_OS •It Yes.See Sidebar
Z ST CHARLES IL 60174-1610 0 1 0 FQ44385 IL 2026 REAR 4 Si)C
M
IL D 0 1 HGCM56844A072218 First Chicago Insurance ❑Y ®N RDEF M
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER • 1 X
Delgado.Adriana 1 LS1062801-01 SAC • E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((A.DDRESS)((TELEPHONE) • (EMS) (HOSPITAL)
2 3 11 /
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/ / UI IM
/ / 3 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME • DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 1 10/61 ,025 03 05 ®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 • �
0 2 0 28 03 + ) ❑PM ❑Construction *
R 3 0 xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM ❑Maintenance U2
o ® 11 1 ARREST NAME Lafrance.Olivia. R. 11-601-Ax W1525000766 ! / El PM SLMT
o N 0 CITATIONS ISSUED • ❑
PENDING SECTION CITATION NO. ROAD CLEARANCE TIME Utility
0 AM
t 2 El ARREST NAME 10+6) 1025 03 57 ®PM El Unknown work zone type U1 30
, T
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
❑Y 30
1525-Nave.Oscar 601 - 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.
r ----r••--, , ® ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
i- i-___-r____1 I _ 1. Has
or more than pound (example:truckortruck/trailerc -I 1. Has a weight rating10 000 5
1.
Not To Scale j INDICATE NORTH tan) p3
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} I - } ,. • (example:shuttle or charter bus):or 0
I 3. Is designed to carry15 or fewer passengers and operated a contract carrier 0
I- -A-.-.-I Z
} } } transporting employee �In the course of their employment(example:employee
rter-
y a van type
L L.___a__._' j I 4alsuosedordesllnatedtotransehrtbetweeicle or n9andr15r) ssen rs,induding[hedrNer. C
} } } for direct compensation(example:large van used for specific purpose):or 0
L L____a.....I L } t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). ;p
.......................................... : 1.$2. s • I
/ CARRIER NAME
/ / ADDRESS 'Z
ICITY/STATE/ZIP C)
_ MOTOR CARR.ID El Interstate El Intrastate
1 I r 1 I ❑ Not in Comm./Govt. 0 Not in Comm./Other
1 ‘I.
, _Y_ _. I USDOT NO. ILCC NO. m
XI
Source of above 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
71
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
Tan Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE