HomeMy WebLinkAbout2025-00071510 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 Mil it ll 1111
fl
III IIIIIIII I II
DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X004016033
u, 1 U2 17 4 1 U1 2 U2 U1 1 1_12 U, 1 U2 1 1 U1 1 U2 *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 ❑$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 2025I 2025-0007151 O VEHT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
1566 LARKIN AVE El In07:22
® ❑ RELATED ❑Y ®N 11 03 2025 ®AM ❑YES ®NO U1
g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
_
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW Cl)
❑ FT/MI N E S W Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIA/ 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
0 1 /
yr Honda CRV 2024
13-UNDER CARRIAGE 10 12! 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 2 M
M 2 SY4 ❑Y ®SNEM IN ft❑UNK VEH. O ATCRASHH D 0 99-UUTHER NKNOWN 9 16•TOP 3 `DistractionValue 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s 1 6 �i 4 COM VEH 0 0 1 0
~ SchaumbergI L 60195 0 1 0 FIRST CONTACT 2 7 . -_5 *lI Ves.See Sidebar Ut
Z EF33922 IL 2026 E
TELEPHONE
IL D 0 5J6RS4H21 RL003784 Progressive ❑Y igi N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
1 48 2 Hairston. Dometrise.O. 976551452 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 XI
0 DRIVER 0 PARKED 0 DRIVERLESS N PED 0 PEDAL 0 EWES 0 NMV 0 NCV 0 DV
yr 12 ,_ 71
Ti 13-UNDER CARRIAGE 10.i 2 FIRE 0 0 U2 C
F ❑Y ❑N D UNK VEH. AT CRASH 99-UNKNOWN •OistractlonValue 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s-it 6 1:--4 COM VEH 0 0 U1 CO
FIRST CONTACT 15 7�� _REAR . fA
5 •IfYes,See Sidebar C
H ELGIN IL 60123 B
0 Y 0 N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Elgin Fire 1 48 2 Hairston. Dometrise.O. SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE:ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((A.DDRESS)(TELEPHONE) (EMS) (HOSPITAL)
1 3 01 / M 2 3 0 1
m
/ / #OCCS D
71
/ / u1 2 D
/ / 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
u 1 ® 12 1 11 ,3/ l025 07 22 ®❑Pmm� in a Work Zone? ®N DIRP co
I t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
;, 2 0 24 99
! , 0 PM• 0 Construction >F
R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME
❑AM 0 Maintenance U2
a1 ® 12 1 ARREST NAME Pritchett. Demetrius.m. 11-307 1531000189 , / El PM SLMT
o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
20
t 2 1 / ❑❑ 11 1 ARREST NAME AM
7 ❑PM 0 Unknown work zone type U1
2 2 3 ❑ 11 1 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 2O
1531-Schzmbach.Jack 602 12 , 9/ ,025 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.
^ 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 -<
combination):or —I
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
L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
} - } transporting employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
L L.___a____� 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or 0
i. i _ 5. Is anyvehicle used to transport anyhazardous material(HAZMAT)that requires
A n Jl
placarding(example:placards will be displayed on the vehicle). �
—1
r u,r1 CARRIER NAME Z
` _—_, 'in
u^rrs ADDRESS D
wsaa
rn
0
CITY/STATE/ZIP g
S1i. i. i. i. MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. Not in Comm./Other
Y Not To Scale j USDOT NO. ILCC NO.
m
XI
Source of above z
. 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' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Silver
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: 1 TOWED BY/T6
DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE