HomeMy WebLinkAbout2025-00065813 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X063989901
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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 ®5501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00065813 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 71
® ❑ RELATED ❑Y ®N 10 07 2025 ❑AM ❑YES ®NO U1 -<
LARKIN AVE Elgin04:18
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W MARKET ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 '
❑ Kane HIT&RUN ❑V ® N WITH VEHICLESOT,
INVLD DO
U2 --I
E j AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
0 DRIVER ❑ PARKED ❑DRIVERLESS Ig) PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
1 0 /
yr NONE
12 -
13-UNDER CARRIAGE i DUE TO CRASH ❑ 0
10 i • 2 FIRE 0 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
M 1 3 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 _
El N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s_i L S 4 COM VEH 0 0 1
c Z E LG I N IL 60124 0 1 0 FIRST CONTACT 00 7_; _5 *II Yes.See Sidebar Ut
0
REAR
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1)
( 0 ❑Y 0 N U2 St . m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 1 64 2 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
Other O POt E eU
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m �{ DElVER ❑ PARKED 0 DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 r uv 0 NOV 0 Dv
0 0 6 Hyundai Tucson 2020' 00-NONE 11'f 12 (,-2 FIRE DUE ID
CRASH 0 ® U2 2 C
o mo 13-UNDER CARRIAGE
c
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN •Dist/neon Value 9 0
POINT OF 8 1�" 4 COM VEH D ® U1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 12 7 6 .5 •If Yes.See Sidebar
— Davis Junction IL 61020 0 1 0 576AC372 IL 2025 I 0 Si)c
Z
IL D 0 KM8J3CA45LU103034 NIA ®Y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same NIA SAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 12 5 10/71 /025 04 18 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below:
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AMU1
v 2 14 99 10,71 /025 04 24 ®pm ❑Construction
R 1 3 ❑ ]$I CITATIONS ISSUED ElPENDING SECTION CITATION NO. EMS ARRIVED TIME 1
z J ❑AM ❑Maintenance U2
a1El 12 5 ARREST NAME Cicogna.Alden.C. 3-707 S1924-000477 10/71 /025 04 24 igi pM SLMT
o N 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility
0 AM
T 2 ElARREST NAME 10/71 /025 05 00 0 PM ❑Unknown work zone type U1 30
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1524 Silva Jose 602 11 , 18,2025 09 00 ❑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 truckrtrailer -<
___-r----; I INDICATE NORTH combination):or —I
p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
(example:shuttle or charter bus):or 0
r r X
3. Is designed to carry15 or fewer passengers and operated a contract carrier O
`
----------J. Market93t 8 1 `
. . . transporting employee In the course of their employment(example:employee
y a van type
< <.___a____� uwn ,. 4alsuosedordrter- estlnatedto transport betweeicle or n9 and r15r) ssen rs,including the driver.
TIudnz t } } for direct compensation(example:large van used for specific purpose):or 0
JAtIV L } t 5. Is anyvehicle used to transport anyhazardous material(HAZMAT)that requires
�..na placarding(example:placards will be displayed on the vehicle). .Zm1
CARRIER NAME Z
Laddn4Ave. - ADDRESS O
® 0
. CITY/STATE/ZIP
Not To Scale MOTOR CARR.ID 0 Interstate 0 Intrastate
I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other
----- - '-1 - USDOT NO. ILCC NO. rn
XI
Source of above z
. IDOT PERMIT NO. WIDELOADo ❑Yes 0 No =
TRAILER VIN 1 m
to
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 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Black
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT: 4 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