HomeMy WebLinkAbout2025-00071443 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY XO040160r43
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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 ®5501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ❑OVER 31,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 2025I 2025-00071443 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED PRIVATE ❑Y ®N 11 02 202512,— ❑YES ®NO U1 -<
N LIBERTY ST Elgin mo /day/yr 06:09 ®PM FLOW CONDITION Ill
I 0 ®!MI N E 0 W GRAND Ave COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR ElSLOW 1 CA
Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
gi DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
NAME(LAST,FIRST,M) J EN NA.JEAN MARIE mo Honda Civic 2008 00-NONE „ • O , DUE TO CRASH ❑
EN
13-UNDER CARRIAGE 1U i ' 2 FIRE 0
2
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL)THERDISTRACTED 0 ]$I U2 m
F 2 4 SYTM❑Y ®SNE❑UNK VEH. O AT CRASH 0 15-99-UNKNOWN 9 76•TOP 3 ,Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 7_iL 6 4 COM VEH 0 El 1 0
H 1- HOFFMAN ESTATES IL 60192 0 1 0 FIRST CONTACT 12 Y ; _s *Irves.seesidabar Ut
Z DQ69500 IL 2026 E
TELEPHONE
IL L 0 1 HGFA16838L115794 PROGRESSIVE ❑Y ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
ro
Elgin Fire 99 9 BUKENYA.JOWERIA 990195578 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER
2 ou
g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 New 0 NOV 0 Dv
/1 9 8 7 Honda Civic 2006 00-NONE ,i j 12..-_, DUE TO CRASH ❑ !g 2 x
.. yr 13-UNDERCARRIAGE ta;l 2 FIRE ❑ ® U2 C
c
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistracton Value 0
POINT OF s iI 4 COM VEH ❑ ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR - 6 �'_
FIRST CONTACT 6 Y_{_ r-s •IfYes,SeeSidebar
= Elgin IL 60123 B 1 0 FL73213 IL 2026 I AR 0 Si)c
IL D 0 2HGFG12866H565258 AMERICAN ALLIANCE ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire 99 9 Same I LAA100404200 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(A.DDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
2 3 10 /
:A
/ / UI 1 D
/ / 3 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 1 11 /21 /025 06 09 0 AM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
v 2 28 15 11/21 /025 06 09 ®PM El Construction
>E
R O 0 ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
3 ❑AM ❑Maintenance U2
-a, ARREST NAME J EN NA.J EAN MARI E 11-601-Ax 433001546 11/21 /025 06 12 ®PM SLMT
1 ® ElUtilit 11 1 0 CITATIONS ISSUED ❑PENDING
o NSECTION CITATION NO. ROAD CLEARANCE TIME y
t 2 El ARREST NAME 1 1/21 /025 06 27 ®PM El Unknown work zone type U1 0 AM 30
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 30
433-Miracle. Matthew 202 11 , 18/2025 01 30 ®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 i----r-•--, , I - A CMV is defined as any motor vehicle used to transport passengers or property and: Z
�____r____; I L4._.
_ combination):or g ore than , pound ( a p .truck ortruckrtrarler 0 -<
1. Has a weight ratio m 10 000 5 ex m le
INDICATE NORTH -I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
0 _ (example:shuttle or charter bus):or
<____ �____. Not To Scale I 3. Isdesgnedto carry 15or fewer passengers and operated bya contract carrier I O
} } } transporting employees in the course of their employment(example:employee X
I r lOr 'id7A l I transporter-usually a van typecar):vehicle or passenger ca):or cC
o- I. } 1. •4. Is used or designated to transport between 9 and 15 passengers,including the driver,
for direct compensation(example:large van used for specific purpose):or 0
L L____a____. t i. i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires III
(example:placards will be displayed on the vehicle). m
XI
CARRIER NAME Z
i ADDRESS
D
wI CITY/STATE/ZIP zIP ng�
I _ MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I I ❑ Not in Comm./Govt. Not in Comm./Other
I I '
USDOT NO. ILCC NO. m
—Y XI
Source of above z
.
Were HAZMAT placards on vehicle? 0 Yes 0 No =
If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. Xl
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 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
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
Beige Black
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 1 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE