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HomeMy WebLinkAbout2025-00066477 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 11111111 11111111 00100100 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003989845 u, 1 U21 2 4 1 U1 5 U2 1 U, 1 1_12 1 U, 1 U2 1 1 10 U1 3 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW ' Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 14 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) El B Injury and f or Tow Due To Crash El AMENDED YR 2025I 2025-00066477 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 mSOUTH ST El11:57 ® ❑ RELATED ®Y 0 N 10 10 2025 ®AM El YES ®NO U1 _ _ g PRIVATE mo !day/yr ❑PM FLOW CONDITION MFT!MI N E S W DE PAU L DR COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 1 (/)❑ Kane 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 Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0 r T TOWED U1 Salzmann. Pamela.S. Buick Enclave 2018 00-NONE ©1 • Q2 i 01 DUE TO CRASH ® ❑ NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 10 1 2 FIRE 0 al STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 rn F 2 SY n 15-OTHER 4 ❑Y ONM❑UNK VEH. AT CRASH IN n D 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, it B �i COM VEH 0 Ea 1 0 ~ ELGIN IL 60123 0 1 FIRST CONTACT 1 7 ; __5 *IIYes.SeeSidebar Ut Z BV52389 IL 2025 E TELEPHONE IL D SGAEVBKWXJJ277448 State Farm ❑Y ®N U2 m .5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Elgin Fire Same 0130191-SFP-13 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y El 2 0 m g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 r uv 0 NOV 0 DV !2 0 0 3 Mercedes-Ber250 Series 2013 00-NONE 0. Q1-_1 DUE TO CRASH 0 p 2 x 0 y Yr 13-UNDER CARRIAGE 10( I 2 FIRE ❑ ® U2 C c F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value 0 i1I N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 4 COM VEH ❑ ® FIRST CONTACT 11 8 7 •_5 •If Yes.See Sidebar U1 CO • — Lake in the Hills IL 60156 0 1 0 EF74507 IL 2026 REAR0 N IL D WDDGJ4HB6DG060005 Progressive ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 = Same 987890245 BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPOND O N U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) W 07 / U1 1 D / / 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 4 co 10,10 /2025 11 1 57 ®❑PM AM in a Work Zone? ®N DIRP D 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 2 ❑ 14 23 N 3 0 0 CITATIONS ISSUED 0 PENDING ! 1 ❑PM El Construction SECTION CITATION NO. EMS ARRIVED TIME ❑AM El Maintenance U2 3 —a, ARREST NAME ! ! ❑PM ' o N 1 ® 11 4 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ,_,Utility SLMT 30 t 2 ARREST NAME AM 7 1 r O PM ❑Unknown work zone type U1 El OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ - ❑AM Workers present? ❑Y 30 426-Joniak. Matthew 702 , , ❑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 -< ` ` --1 -' r INDICATE NORTH combination):or —I 4 N= SOuth?St BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C i - } (example:shuttle or charter bus):or L l .--; _ I transportng mployeeslln 5 the courses passengersr thir emplod yment example:employeener 0 } A } } Not To Scale II [.. t transporter-usually a van type vehicle or passenger car):or 0 L 4. Is used or designated to transport between 9 and 15 passengers,including N --- ----; - } } } g po passen rs,includi the driver, 1 : for direct compensation(example:large van used for specific purpose):or O .... Jam' A-' _ i i t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m i . placarding(example:placards will be displayed on the vehicle). X/ , /= 1.1;I - a I ,. -- `` 1 CARRIER NAME Z ADDRESS T I DePaul?Dr T. CITY/STATE/ZIP n g MOTOR CARR.ID 0 Interstate 0 Intrastate : : . : ❑ Not in Comm./Govt. 0 Not in Comm./Other --- --1 - USDOT NO. ILCC NO. m XI Source of above z . —I Were HAZMAT placards on vehicle? 0 Yes 0 No = If Yes,Name on placard O 4 digit UN NO. 1 digit Hazard class No. XI Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z own tank)? 0 Yes 0 No 0 Unknown Did HAZMAT Regulations violation contribute to the crash? r ❑ Yes 0 No 0 Unknown M 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 Xl 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 0 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Black Black u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE