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HomeMy WebLinkAbout2025-00067094 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 011011001 0110 0 100 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00399285/ u, 1 U21 1 1 1 U1 2 U2 1 U, 1 u2 1 U, 1 u2 1 4 10 u1 3 u2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 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 1 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash El AMENDED YR 2025I 2025-00067094 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 RT20 El ❑ RELATED ®Y 0 N 10 13 2025 08:13 DAM ❑YES ®NO U1 Elgin PRIVATE mo /day/yr ®PM FLOW CONDITION III FTlMI N E S W LONGCOMMON PKWY COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n ❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEON. 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 FOR DAMAGEDAREA(S) FROM TOWED U1 0 Valle John. F. 0 1 / yr 13-UNDER CARRIAGE ©, :: FIRE 0 ® < STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ga U2 M M 2 4 ❑Y ®Nn is-OTHER SYSTEM ❑UNK VEH. AT CRASHD 99-UNKNOWN 9 16-TOP 3 *Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�S �i COM VEH 0 j$J 1 0 0 ELGIN I L 60124 0 1 0 FIRST CONTACT 11 7_: __5 *II Yes.See Sidebar U1 Z EM45303 IL 2024 REAR TELEPHONE IL D 0 1 C4RJ FAG9EC205227 none ®Y ❑N U2 m .5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same none 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' 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 ro,IV 0 KKv 0 Dv /2 Yr 0 0 6 Subaru Legacy 2015 00-NONE OI t2 c, 2 FIRE O CRASH 0 U2 C D 2 .. 13-UNDER CARRIAGE c F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 X ❑Y Ni N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraglon Value 0 POINT OF 8 i1� 4 COM VEH ❑ ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6 FIRST CONTACT 11 7 _,__5 •If Yes.See Sidebar z ELGIN IL 60124 0 1 0 FC95283 IL 2026 I 0 C IL D 0 4S3BNEN67F3058702 American Family ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X 99 9 Donato. Paul AX01046560 BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) W 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 10,13 /2025 08 13 ®AM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 6 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 0 v 2 0 2 18 10,13 /2025 08 18 ®PM ❑Construction * R 3 0 gi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 z J ❑AM ❑Maintenance U2 -a, ARREST NAME Vallery.John. F. 11-901-A 1560000120 10/13/2025 08 24 ®pM SLMT o u1 ® 11 4 •El CITATIONS ISSUED 0 PENDING Utility o N SECTION CITATION NO. ROAD CLEARANCE TIME AM• ❑ t 2 El ARREST NAME Vallery.John. F. 3-707 1560000121 10,13 /2025 09 06 ®PM El Unknown work zone type U1 45 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 45 1560-Jones. Bennett 801 11 ,04,2025 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 p0 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } J LI. Not To Scale 1 - (example:shuttle or charter bus):or 0 L A I � 3. Is desgned to carry 15 otr fewer passengers and operated by a contract carrier 0 } } } transporting employees in the course of their employment(example:employee X transporter-usually a van type vehicle or passenger car):or CO L L.___a__ 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including C} } for direct compensation(example::large van used for speific purpoe):o i ll, - i i _ 5. Is anyvehicle used to transport anyhazardous material(HAZMAT)thatrequiresrive 'D m `. ._ �. placarding(example:placards will be displayed on the vehicle). ;p Uric R1 , , , , , CARRIER NAME Z Z ADDRESS 0CITY/STATE/ZIP 0 1..r 'n°'""°"�awx - i. MOTOR CARR.ID 0 Interstate 0 Intrastate 1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other ‘I. - --1 - USDOT NO. ILCC NO. m XI Source of above z . Xl 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 I 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 to 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 White Blue 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 DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE