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HomeMy WebLinkAbout2025-00072348 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I0110 1111 1011111111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X�024688 u, 1 U2 1 1 1 U116 U2 u, 1 u2 u, 1 U2 4 6 u, 1 U2 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ❑5501-51.500 ®ON SCENE 2 VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash 0 AMENDED yR 202512025-00072348 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ® ❑ RELATED PRIVATE ❑Y ®N 11 07 2025DAM El YES ®NO U1 -< ROUTE 20 Elgin mo /day/yr 11:44 ®PM FLOW CONDITION M ®15(() !MI N E s © Lambert Ln COUNTY PROPERTY ❑Y MN DOORING ❑y #OF MOTOR 0 SLOW Cl) Cook 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 18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 NOV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 6 0 FOR DAMAGEDAREA(S) FROr T TOWED U1 Q NAME(LAST,FIRST,M) Oghenemase. Fasetire. K. 0 8 / yr 13-UNDER CARRIAGE 101 •�. 2 FIRE 0NI STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ Ea U2 rn M 2 6 n is-OTHER ❑Y ®N SYSTEM ❑UNK VEH. AT CRASH D 99-UNKNOWN 9 16•TOP 3 ,Distraction Value 9 ALGN = r • CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s_iL s I,,4 COM VEH 0 Ea 1 O F. FIRST CONTACT 1 7. ;• ; - *Ir Ves.See Sidebar U1 —__5 Z Chicago IL 60612 0 1 FE47066 IL 2026 TELEPHONE IL D 4T1T11AK8RU919522 Geico ❑Y ®N U2 n-i 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same 6199801017 1 r o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ❑ N 2 rg- 0 DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 Nuy 0 NOV 0 DV yr 12 - C o 13-UNDER CARRIAGE 10.i t, 2 FIRE ❑ ❑ U2 C c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 ❑ ❑ SPDR 0 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistraellon Value U1 0 - POINT OF 8-.;, 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT YA='+:=5 COM•I sVEH •Sidebar❑ 0 C CO F` ---,- co See M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O ❑y ❑N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = BAC HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < RESP❑YDNDER❑N U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) 0 U2 m / / #OCCS > / / UI 2 D / / 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ID 43 1 11 /08 /2025 11 44 ®pm in a Work Zone? ®N DIRP 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 ❑ 10 28 ! / ❑PM. ❑Construction t R 3 ❑ I!!I CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 et ARREST NAME Oghenemase. Fasetire. K. 12-101 W1543000382 / / ❑PM SLMT oN 1 ❑ ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility t 2 ❑ ARREST NAME AM 7 / / pM El Unknown work zone type 45 U1 n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME y 2 3 ❑ - ❑AM Workers present? ❑ 1534-Santiago.Jorge 401 / / ❑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 Not To Scala , ADDITIONAL UNITS FORMS. r ----r••--, , - ; 0 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 -< i- i--- --I-- ---I. i II INDICATE NORTH N- BY ARROW combination):or 2 Is used or designed to transport more than 15 passengers including the driver C - (example:shuttle or charter bus):or 0 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 72 transporter-usually a van type vehicle or passenger car):or co — — — — Route?20?wlb Rouro7207�arb C < L____A____; Lambert7Ln _ I. I 1 •4. Is used or designated to transport between 9 and 15 passengers,including the driver. w for direct compensation(example:large van used for specific purpose):or O L L____a____. I 41 a - L i I _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m placarding(example:placards will be displayed on the vehicle). CARRIER NAME Z u _ __ ADDRESS 'O I T. CCITY/STATE/ZIPg C) _ MOTOR CARR.ID 0 Interstate 0 Intrastate 5 I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other 0 • USDOT NO. ILCC NO. C m 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. XI 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 M 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 0 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U_COLOR TRAILER LENGTH(S)1 ft. 2 ft. w White u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT' 3 TOWED BY/TO: _ . SELECT CODES FROM THE BACK OF CRASH BOOKLET U_DUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO. DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE