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HomeMy WebLinkAbout2025-00066506 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 1011011001000111111100 00 00 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0039899 6 u, 1 U21 1 1 1 U1 2 U2 1 u, 1 1_12 1 1.11 1 U2 1 1 10 u, 3 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash 0 AMENDED YR 2025I 2025-00066506 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 mBLUFF CITY BLVD Elgin ® ❑ RELATED ❑Y ®N 10 10 2025 ❑AM ❑YES ElPRIVATE NO U1 mo /day/yr 02:42 ®PM FLOW CONDITION m 01 O(�!MI N E S ® St Charles St COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 cn Cook HIT&RUN ❑Y ® N WITH VEHICLES INVLD 00 STOPPED U2 '--I 0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C) FOR DAMAGEDAREA(S) FRCf4r�TOWED U1 0Mallett. Michael. L. 1 2 / yr 13-UNDER CARRIAGE 1U 1 2 FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m M 2 4 ❑Y ®SNEM❑ n 15-OTHER UNK VEH. AT CRASHIN n ENGAGED 99-UNKNOWN 9 16•TOP 3 `Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�S �i COM VEH 0 j$J 1 0 ~ Hanover Park IL 60133 0 1 0 FIRST CONTACT 1 7_: __5 *IIYes.SeeSidebar U1 ZDW94516 I L 2025 REAR TELEPHONE IL D 0 3MVDMBCMXPM534936 PROGRESSIVE ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m BUDZ. MARY. K. 974141773 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 XI N DRIVER ❑ PARKED 0 DRIVERLESS ❑ FED ❑PEDAL 0 EWES ❑iiuv 0 i v ❑DV !1 9 8 1 Honda Accord 2012 00-NONE O', 2 L 0 DUE TO CRASH ❑ 2 x 0 13-UNDER CARRIAGE 9 I ©). 2 FIRE ❑ ® U2 C c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 X ❑Y Ni N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistrac on Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S-it 6 �1:, 4 COM VEH D ® U1 CO FIRST CONTACT ii 7 ,__5 C. (ryes.See SidebarC H ELGINZ IL 60120 0 1 0 V436394 IL 2025REAR M IL D 0 1 HGCP2F70CA094647 STATE FARM ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X Same 0727430SFP13 BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused 0 Y°ND 0 N u1 = (UNIT) (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 ❑Y U2 Z u 1 ® 11 1 10,10 (2025 02 42 ®AM in a Work Zone? ®N DIRP co 1 1 PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 5 C) T 2 ❑ 2 06 ( ( 0 PM ❑Construction * 04 R 3 ❑ $I CITATIONS ISSUED 3 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 o1 ® 11 1 ARREST NAME Mallett. Michael. L. 11-902 456-432(w) ( r El PM SLMT o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility 1 2 ❑ ARREST NAMEAM c- T ( / ❑❑PM ❑Unknown work zone type 45 U1 n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 El ❑AM Workers present? ❑Y 45 456-Romalo.Carmine 401 - ( ( ❑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 -< ` ` --I -' r INDICATE NORTH combination):or —I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } - } r r ,. (example:shuttle or charter bus):or HINAMIIIHNOT 0 I I () 3. Is designed to car 15 or fewer ssen ers and o rated a contract carrier 0 }----- -•-• J I N - } } } } transportingemployees In the course of their employment ployment(example:employee X transporter-usually a van type vehicle or passenger car):or w L i. __}----; - — — —— - • } } } 4. Is used or designated to transport between 9 and 15 passengers,including[he driver, N for direct compensation(example:large van used for specific purpose):or O airos L i UNT= _ _ __ t i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D — placarding(example:placards will be displayed on the vehicle). m r __ XIr BUM c,omnw 1 I I I I 1 D CARRIER NAME —I Z Not To Scale I _ __ ADDRESS CITY/STATE/ZIP 00 MOTOR CARR.ID 0 Interstate 0 Intrastate l I r l ❑ Not in Comm./Govt. 0 Not in Comm./Other ------------ - USDOT NO. ILCC NO. rn XI Source of above z . 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 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 Xl IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2 TRAILER VIN 1 m co LOCAL USE ONLY TRAILER VIN 2 m v TRAILER WIDTH(S) 0-96" 97-102" >102' T TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 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: 2 TOWED BY/TO: DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE