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HomeMy WebLinkAbout2025-00071884 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 10110 ll 1111 fl 101000 I 0 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004013211 u, 9 u21 1 1 1 Ut 2 U2 1 U,99 1_12 1 U,99 U2 1 1 11 U1 1 U211 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT 0 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$1,500 El NOT ON SCENE(DESK REPORT) (83B Injury and/or Tow Due To Crash El AMENDED YR 202512025-00071884 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 mKI M BALL ST El11:24 ® ❑ RELATED ❑Y ®N 11 05 2025 ®AM ❑YES ®NO U1 _ _ g PRIVATE mo !day/yr ❑PM FLOW CONDITION MFT!MI N E S W N GROVE AVE COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR El SLOW 3 Cl) ❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD ® STOPPED U2 --I Igl AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 / / T FOR DAMAGEDAREA(S) FROM�TOWED U1 0 Unknown.0. Honda Civic 2007 00-NONE ©, >2 �/DUE TOCRASH ❑ EN NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 10.I 2 FIRE ❑ (E < STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ ]$I U2 M SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 M 9 9 ❑Y ❑N DUNK VEH. AT CRASH 99-UNKNOWN 6 4 `Distraction Value ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 �i COM VEH ❑ Ea 1 00 0 9 FIRST CONTACT 12 7_: __5 *lIVes.See Sidebar U1 Z FB40190 IL 2025 REAR TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1) 2HGFG12647H530637 Unknown ❑Y ❑N U2 I- 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Pacheco Villada.Angelica. M. Unknown 1 rn `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 99 0 x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 New 0 Nev 0 DV !1 9 6 9 Honda Odyssey 2008 00-NONE It-' 12--- DUETO CRASH ❑ C 2 73 o 13-UNDERCARRIAGE 10;1 2 FIRE ID El U2 C c F 2 4 SYSTEM IN ENGAGED 15-OTHER 9 16•TOP 3 3 X ❑Y ❑N DUNK VEH. AT CRASH 99-UNKNOWN *0istracton Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 iII 6 ..,_4 COM VEH D ® Ut CO FIRST CONTACT 6 Y__{_O ._5 ••(ryes,See Sidebar n E LG I N IL 60120 B 1 E702857 IL 2020 REAR Z IL D 5FNRL38428B409413 Bristol West ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X Elgin Fire Same G01671197500 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 < Refused RESPONDER u1 = (UNIT) (SEAT) (DOB1 (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 2 3 08 / DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 9 11 !05 l2025 11 24 ®p PM AM in a Work Zone? ®N DIRP D 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 0 28 99 N 3 ❑ ❑CITATIONS ISSUED 0 PENDING • ! 1 ❑PM ❑Construction >F SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 7 -a ARREST NAME / / ID ' o u ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT , 30 t 2 ARREST NAME AM 7 ! r ❑❑PM El Unknown work zone type U1 El OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 - ❑AM Workers present? ❑Y 30 345-Gomoll.Geoffrey 102 ! ! El 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 -< c ` --I -' r INDICATE NORTH combination):or .Z-1 1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C (example:shuttle or charter bus):or n r r X eoi1,, onftA,,,,,p 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O I - } } } transporting employees In the course of their employment(example:employee transporter-usually a van type vehicle or passenger car):or w C L L.___a____. -tea I. } 4. Is used ordesi natedtotrans rt between 9 and 15passengers,includingthedriver, } for direct compensation(example:large van used for speific purose):or 0 L -a-___. - t i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires •u — placarding(example:placards will be displayed on the vehicle). XI CARRIER NAME Z i. Z 0Nof To Scale I 1 1 r .:. i... .4. ADDRESS D , C) CITY/STATE/ZIP 0 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. m XI Source of above z . • m 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 Silver Gray 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