HomeMy WebLinkAbout2025-00065376 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 011011001 00101000
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003989810
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 3
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and f or Tow Due To Crash YR 2025512025-00065376 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
LONGCOM MON PKWY El In04:39
® ❑ RELATED ❑Y ®N 10 05 2025 ❑AM ❑YES El NO U1 -<
g PRIVATE mo !day/yr ®PM FLOW CONDITION m
FT!MI N E S W BEACON POINT CIR COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!Cy 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FROM TOWED U1 Q
Cassid Madeline. R. Chevrolet Malibu 2003 00-NONE „ , DUE TOCRASH ❑ EN
NAME(LAST,FIRST,M) y mo yr 13-UNDER CARRIAGE 1a.I 2 ' 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
F 2 SY4 ❑Y ®SNE❑UNK VEH. O AT CRAS IN H O 99-UNKNOWN 9 76•TOP 3 `Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 iI 6 4 COM VEH 0 j$J 1 0
F.
Bartlett I L 60103 0 1 0 FIRST CONTACT 12 7 ;{ _5 *II Yes.See Sidebar U1
Z EX39198 IL 2026 REAR
TELEPHONE
IL D 0 1 G 1 N E52JX3M597707 State Farm ❑Y Il N U2 I—
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
99 9 Cassidy. Matthew.T. 2667868-SFP-13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 XI
N DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 m y 0 NCv 0 Dv
!1 9 yf 4 Volkswagen Jetta 2019 00-NONE ,i"j 12--_, DUETO CRASH ❑ ® 3 x
o 13-UNDER CARRIAGE ta;l 2 FIRE 0 ® U2 C
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP 3 X
❑Y EQ N ❑UNK VEH. AT CRASH 99-UNKNOWN •Oistracl n Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 iI 6 _4 COM VEH ❑ ® U1 CO
FIRST CONTACT 6 Y :j= _5 •(ryes,See Sidebar C
n ELGIN IL 60124 0 1 0 9200173 IL 2026 aR Si)0
IL D 0 3VWC57BUXKM084753 StateFarm ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 0493441-SFP-13 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER
U1 =
KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(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 10,05 l2025 04 39 ®pm in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
0
2 28 99 ! ! ❑PM• ❑Construction *
R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM 0 Maintenance U2
oEl 11 1 ARREST NAME Cassidy. Madeline. R. 11-601-Ax 1527000363 / ! El PM SLMT
o N 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility
0 AM
T 2 ❑ ARREST NAME 10!05 l2025 05 00 0 PM 0 Unknown work zone type U1 3O
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 30
1527-Juarez.Jorge 801 282-St.John 10 ,28,2025 01 30 ®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 rs 1. Has a weight rating more than 10,000 pounds(example:xamp truck or truck trailer -<
combination):or —I
INDICATE NORTH p1
9 P.o.1. : BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ } (example:shuttle or charter bus):or C)
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
ft L L.___a__ - } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver,
C
`- Bet POI
for direct compensation(example:large van used for specific purpose):or to
L ��. t i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m XI
(example:placards will be displayed on the vehicle).
—1
r. CARRIER NAME
Z
ADDRESS T.
0Jisraamr_ w C)
CITY/STATE/ZIP 0
MOTOR CARR.ID 0 Interstate 0 Intrastate
�• ❑ Not in Comm./Govt. ❑ Not in Comm./Other 00
:- --- --1
USDOT NO. ILCC NO. C
1 .: 7 3
m
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 Black
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