HomeMy WebLinkAbout2025-00067021 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
011011001 01001 110
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003998181
u, 1 U21 13 7 2 u, 8 U2 4 u, 1 u2 1 u, 1 U2 1 1 8 u, 13 U2 1 *P 0119
INVESTIGATING AGENCY DAMAGE TO ANY ®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 8
VEHICLE/PROPERTY ElOVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 2025I 2025-00067021 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 16 �I
® ❑ RELATED ❑Y ®N 10 13 2025 IgIAM ❑YES ®NO U1 -<
RT20 WB ENT RAMP Elgin11:11
_ _ g PRIVATE mo !day/yr ❑PM FLOW CONDITION m
FT!MI N E S W S STATE ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR IR SLOW 1 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0
0 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 NOV Q'q icy 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
0 9 !
yr
13-UNDER CARRIAGE 10 i 12 2 FIRE 0 IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 2 m
M 2 3 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 _
❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction value ALGN
r COM VEH El El 1 CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 1S 4 0
~ 7
FIRST CONTACT 00 7 Elmhurst I L 60126 0 1 0 NIA I L _;Ismi
_5 *Yves.See Sidebar Ut 2
2 Z
TELEPHONE
IL A 7 52155 National Interstate ❑Y ®N U2 1-
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
co
Stevenson Crane Sery SCR000053502 2 m
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
t RESPONDER
E ( U eu
N DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMv 0 NOV 0 DV
!2 0 0 6 Mazda Mazda 3 2007 00-NONE 1I__' 12 0 DUE TO CRASH rg ❑ 2 x
omo 13-UNDER CARRIAGE 10 2 FIRE ID El U2 C
c
M 2 4SYSTEM IN ENGAGED ®-OTHER 916•TOP3 O X
❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `OistraclIon Value
POINT OF S i1 �i COM VEH ❑ ® U1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR A 5
FIRST CONTACT 1 7�' -5 •If Yes.See Sidebar
= Rolling Meadows IL 60008 0 1 0 EQ47038 IL 2026 REAR
3 N
Z
IL D J M 1 BK12F671720658 Echelon ❑Y 123 N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Taylor. Patience,O. EPLP1815607 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP 996 <
Refused E Y°®N u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 9 1 I DOT Concrete barrier scraped 10,13 ,2025 11 11 ®❑AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 ❑ 2300 S DIRKSEN PKWY Springfield) 62784 20 28 r , 0 PM 0 Construction E
R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM ❑Maintenance U2
-a, ARREST NAME Giannini. Nicholas. M. 11-709-A W298001327 , ! El PM SLMT
a u1 0 9 1 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME
o • • ❑Utility
N1&.1 AM
r 2 ® 24 3 ARREST NAME Taylor,Anthony.A. 11-601 W298001328 , , DI PM 0 Unknown work zone type U1
o' 45
T
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM workers present? ❑Y 45
298-Lopez, Mirko 701 — , , ❑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__-_1 combination):or
INDICATE NORTH p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- } (example:shuttle or charter bus):or
X
I- I- --I.-•--; transporting Rig employeened to s inthe course 5 or fewer passengers
�heir employdment example:employee a contract rler
enger
C
L •:. .}----+ M_ MI_ — - } } } •
transporter sed or designated to transport between 9 and passengers,15r including the dryer,4 I
"—® --_� � 7 for direct compensation(example:large van used for specific purose):or O
L L____a____. _ t i. i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
Rout•-kontei placarding(example:placards will be displayed on the vehicle). XI
,,-- --/
CARRIER NAME Z
U - ADDRESS D
0
Not To Soele� n
. CITY/STATE/ZIPg
MOTOR CARR.ID 0 Interstate 0 Intrastate
I r ❑ Not in Comm./Govt. 0 Not in Comm./Other
--- --1 - USDOT NO. ILCC NO. m
XI
Source of above z
. Form Number
m
Xl
IDOT PERMIT NO. WIDELOAD' ❑Yes 0 No 2
TRAILER VIM 1 m
to
LOCAL USE ONLY TRAILER VIN 2 m
v
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
Orange Purple
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 0 TOWED BY/TO.
SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® Other/Owners Residence VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE