HomeMy WebLinkAbout2025-00068854 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111
IIIIII II II II III 011100100
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X0040O0825
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRAP/ '
Elgin Police Department ONE PERSON'S ❑5501-S1,500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00068854 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 —n
® ❑ RELATED ®Y 0 N 10 21 2025 ❑AM ❑YES ®NO U1 —<
S EDISON AVE Elgin 04:30
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W ERIE ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 2 fA
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
Igl AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
/83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑NIA/ ❑!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
FOR DAMAGEDAREA(S) FRONT TOWED U1 Q
Andersen.Christine.A. 0 4 /
yr 13-UNDER CARRIAGE ! FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 C)DISTRACTED 0 0 U2 0 IE
m
F 2 SY 15-OTHER
4 ❑Y ®SNE❑UNK VEH. 0 AT CRASM IN H 0 99-UNKNOWN 9 76•TOP 3 `Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6_iL 6 i COM VEH 0 j$J 1 0
F.
ELGIN IL 60123 0 1 0 FIRST CONTACT 2 7_; __5 *IIYes.See Sidebar U1
ZW-315853 IL 2026 REAR
TELEPHONE
IL D 0 19XFC2F57HE005182 AAA 0y ® 4 U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same AUT700873005 2 r
"o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 2 0
N DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMv 0 NCv 0 DV
'1 9 6 0 Nissan Frontier 2024 00-NONE ®. Qi'-_, DUE TO CRASH ❑ 2 x
0 y Yr 13-UNDER CARRIAGE 10( I 2 FIRE 0 ® U2 C
c
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 g
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 11:, 4 COM VEH ❑ ® U1 CO
FIRST CONTACT 11 7� 5 •(ryes.See Sidebar
II". ELGIN IL 60123 0 1 0 6976RK-B IL 2025 g
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M
IL B 7 1 N6ED1 CM7RN647894 Country Financial ❑y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
99 9 Same P12A8197499 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (D051 (SEX) {SAFT) (AIR) (INJ) (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 ® 11 4 10,21 /2025 04 30 ®FM in a Work Zone? ®N DIRP co
1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 3 C1
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2 ❑ 2 99 + / 0 PM• ❑Construction *
R 3 ❑ Jgi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
a1 ® 11 4 ARREST NAME Andersen.Christine.A. 11-901-A 1530000511 / / El PM SLMT
S' N •
0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility
El t 2 ❑ ARREST NAME AM
T / / PM ❑Unknown work zone type 15
U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 15
1530-Soto.Oscar 601 12 / 21 /025 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
til 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- }-- --I-- --' - r INDICATE NORTH combination):or -I
Not To Scale BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- } (example:shuttle or charter bus):or
X
L A I } 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O
} } transporting employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or cC
o
I } 4. Is used ordesi natedtotrans rtbetween9and15passengers,includingthedriver,
p
-...J
} } for direct compensation(exam large van used for speific purose):or
OL
L L____a____. t i i i. _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
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placarding(example:placards will be displayed on the vehicle). ,Zmt
Erle?St— Unit 1 CARRIER NAME z
(: :_ 1 - ADDRESS
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rn
II I� CITY/STATE/ZIP
II - MOTOR CARR.ID 0 Interstate 0 Intrastate
r T . . . . .... 0
❑ Not in Comm./Govt. Not in Comm./Other
0
S?Edlson?Ave USDOT NO. ILCC NO. m
Source of above z
. ❑ Yes 0 No 0 Unknown M
2>
Did Carrier Safety Regulations MCS)violation contribute to the crash? A
❑ Yes No ❑ 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'; 0 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
-71
TRAILER 2 ❑ 0 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Gray Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE