HomeMy WebLinkAbout2025-00070632 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 10110 ll 1111 fl 10 0 0 lI 0
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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 1215501-$1.500 ❑ON SCENE 2
VEHICLE/PROPERTY ❑OVER$1,500 ®NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00070632 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m
S MCLEAN BLVD Elgin 06:00
® ❑ RELATED ❑Y ®N 10 29 2025 DAM ❑YES ®NO U1 -<
_ _ PRIVATE mo !day!yr ®PM FLOW CONDITION m
FT!MI N E S W MAIN LN COUNTY PROPERTY El ® N DOORING ❑y #OF MOTOR IR SLOW 1 (n
❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 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!Cy 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
/ ! FOR DAMAGEDAREA(S) FRONr TOWED U1 0
Unknown.O. Unknown Unknown 00-NONE „ 12 , DUE TOCRASH ❑ EN
NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 101 ! 2 FIRE 0 IE <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 m
SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3
M 9 9 ❑Y El N ❑UNK VEH. AT CRASH ®-UNKNOWN `Distraction Value ALGN =
s 4 COM VEH 0 Ea r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _,)[6 !I,_ 1 00
I— 0 9 0 FIRST CONTACT 99 7_; _5 *II Yes.See&debar U1
REAR
2 Z ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 11/
UNKNOWN ❑Y ON U2 1—
2. EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same UNKNOWN 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y ® N 99 0
g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 1Av 0 NCv 0 DV
yr 19) 12 E FIRE 0 ® U2 C
o 13-UNDER CARRIAGE
c
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOPO3 * X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN Oistracti n Value 9
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-.;, 6 j( 4 COM VEH ❑ ® U1 co
FIRST CONTACT 2 7-'_, _6 •(ryes,See Sidebar
Z SOUTH ELGIN IL 60177 0 1 0 H841360 IL 2026REAR C
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IL D 3FA6POHD4FR302094 Progressive ❑Y ®N RDEF Xj
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 951044009 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (D08) (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
2 6 05 /
, D
/ / 4 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 9 10,29 l2025 07 33 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
2 ❑ 18 99
N 3 0 0 CITATIONS ISSUED 0 PENDING ! 1 0 PM• ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
z
-a, ARREST NAME / / 0 PM '
o u ® 11 5 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
SLMT
30
r 2 D ARREST NAME AM
7 1 r ❑❑PM 0 Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 El ❑AM Workers present? ❑Y 30
562-Hernaindez. Myra 391-Jacobucci ! / ❑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
Not 7b Scale J ( 1 Has a weight rating more than 10,000 pounds(example:truck or truck trailer
} I N combination):or —I
a INDICATE NORTH C
a ?OW BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i - } (example:shuttle or charter bus):or n
t ' I a 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
MNn7Ln
L }-----}---- ' - } } } 4. Is used or designated to transport between 9 and 1 passen passengers,including the driver,
for direct compensation(example:large van used for specific purpose):or
-.
. I 1 t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires a I placarding(example:placards will be isplayed on the vehicle). XI
CARRIER NAME Z
I ADDRESS 0
w
CITY/STATE/ZIP 0
I - i. i. i. 4. MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I , ❑ Not in Comm./Govt. 0 Not in Comm./Other
------- --1 - USDOT NO. ILCC NO. rn
x
Source of above z
. Form Number
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' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Black
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 9 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE