HomeMy WebLinkAbout2025-00072293 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II
III II IIIIII UHI
II II II UI
II111111 11IIIII
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004024701
u, 9 U21 1 1 1 U1 1 U2 1 U1 99 1_12 1 u,99 U2 1 4 10 u, 3 U2 1 *P 0119
INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00072293 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m
WING ST El In04:56
® ❑ RELATED ®Y 0 N 11 07 2025 ❑AM ❑YES El NO U1 —<
g PRIVATE mo !day/yr ®PM FLOW CONDITION m
FT!MI N E S W HUBBARD BBARD AVE COUNTY PROPERTY El ® N DOORING ICIy #OF MOTOR 0 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
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
/
!
FOR DAMAGEDAREA(S) FROM 0 TOWED U1 0
NAME(LAST,FIRST,M) Unknown.O. mo yr Unknown Unknown 00-NONE
13-UNDER CARRIAGE „_' Q T I DUE TO CRASH ❑
) FIRE 0 IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 0
SYSTEM IN
9 ❑Y ❑N ❑UNK VEH. ENGAGED 15-OTHER 9 16.TOP 3 DISTRACTED 0 0 U2 2 m
9 AT CRASH 99-UNKNOWN `Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S_iL S ii,4 COM VEH 0 Ea 1 00
~ 0 9 0 FIRST CONTACT 1 7_; _5 *uYes.See&debar U1
REAR
2 Z ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 11/
unknown 0 Y 0 N U2 I—
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same unknown 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
r D Y°®N 0
m
CIRCLE NUMBER(S) U1
N DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NOV 0 KKv 0 Dv
!2 0 0 4 Chevrolet Equinox 2022 00-NONE OI t2 ! 2 FIRE TO CRASH 0 ® U2 2 73
C
o 13-UNDER CARRIAGE
c
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 X
❑Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value 0
S i1 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF j 5
1!:_ COM VEH•
n H U NTLEY IL 0 1 0 ff39675 IL 2022 FIRST CONTACT 11 7 RFJ
_5 If Yes.See Sidebar C
❑ ® U1 CO
IL D 0 3G NAXU EV8N L180213 Progressive ❑Y ISI N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 997271027 BAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ®Y U2 Z
N 1 ® 11 9 11 ,07 l2025 04 56 ®pm 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 �
2 04 99
N 3 0 ❑CITATIONS ISSUED 0 PENDING + ! - ❑PM• ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ®Maintenance U2 5
—a, ARREST NAME / / ❑PM '
1 ® 11 9 UtilitySLMT
o u SECTION CITATION NO. ROAD CLEARANCE TIME ❑
❑CITATIONS ISSUED PENDING
0 AM
t 2 ElARREST NAME 1 1 r 07 12025 05 00 ®PM ElUnknown work zone type U1 30
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 30
1528-Rivera. Kevin 607 , / ❑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 truckrtrailer -<
` ` -' -' r INDICATE NORTH combination):or .Z-1
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 0
Veln9 } } } transporting employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or CO
L L.___a____.I 00rnie
4. Is used ordesi natedtotrans transport passengers,including C
- } } g po ssen rs,includi the driver,
for direct compensation(example:large van used fors cific purpose):or
L L--_-a-___mo wart L i L 5 Is an vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). XI
—1
CARRIER NAME Z
ADDRESS 0
fMCN7Ave , . , . , W
W
C)
Not 7bS.*i CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
i— --- --1 - 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
to
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
Gray Silver
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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE