HomeMy WebLinkAbout2025-00071691 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets III 11 IIII
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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 El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT) El B Injury and/or Tow Due To Crash
El AMENDED
YR 2025I 2025-00071691 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1
® ❑ RELATED PRIVATE ❑Y ®N 11 04 2025 ®AM ❑YES El NO U1 -<
N MCLEAN BLVD Elgin mo /day/yr 09 23 ❑PM FLOW CONDITION 111
�0 ®!MI N E OS W LARKIN Ave COUNTY PROPERTY ❑Y M N DOORING ❑y #OF MOTOR ❑SLOW 1 cn
Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ® STOPPED U2 -I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
tg:DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
FOR DAMAGEDAREA(S) FRONT TOWED U1 Q
DEVINO. MARK.G. 1 1 /
yr NI
10 I !�. 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 Ea U2 2 m
M 2 4 El ®SNE❑ n is-OTHER
UNK VEH. ATCRASHIN n ENGAGED 99-UNKNOWN 9 16•TOP 3 `Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�a �i COM VEH 0 Ea 1 0
I� 60110 0 1 0 FIRST CONTACT 11 7_; __5 *IIYes.SeeSidebar U1
Z DS25337 IL 2025 REAR
TELEPHONE
IL D SFNYF6H58JB014557 Geico ❑Y ®N U2 M
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
South Elgin Fire 99 9 Same 4055352233 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER 73
D
Sherman ❑Y ElN 2 0
p; DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑l uv 0 NOV ❑DV
y 1 9 9 1 Kia Motors Cogorte 2023 00-NONE 012.._, DUE TO CRASH rg ❑ 2 x
0 Yr 13-UNDER CARRIAGE 10 I 2 FIRE ❑ El U2 C
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F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S-iI�:, COM VEH ❑ ® U1 CO
FIRST CONTACT 11 7� _5 •(ryes.See Sidebar
H ELGIN IL 60123 0 1 0 EA38036 IL 2025 I 0 C
IL D 0 3KPF24AD4PE634488 State Farm ❑Y ®N RDEF 71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire 99 9 Same 2664017SFP13 BAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Provena St.Joseph RESPONDER
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
1 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 ,41 /025 09 25 ®❑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 0 05 20 11/41 /025 09 25 ❑PM 0 Construction *
R O 0 ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
3 ®AM 0 Maintenance U2
—a, ARREST NAME DEVINO. MARK.G. 11-709-A 1558000097 11/41 /025 09 28 ❑PM SLMT
o N ® 11 1 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility
AM
r 2 ElARREST NAME 1 1(41 /025 El pM ElUnknown work zone type U1 40
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? 0 Y 40
1558-Lundvick.John 601 12 / 21 ,025 09 00 ❑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.
- , I I A CMV is defined as any motor vehicle used to transport passengers or property and: Z
} - _--I--- - 0 1~ I I f 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
A I Not To Scale combination):or —I
INDICATE NORTH p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i - } (example:shuttle or charter bus):or
I---- 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
1 transporter-usually a van type vehicle or passenger car):or C
it
L L_____L____.I 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 o
L — — — — — — I. i i. t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). m
1 8 XI
li.mernaxe) ,-,- - -- _I
I ,'F CARRIER NAME Z
r` ADDRESS O
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r CITY/STATE/ZIP o
g
I "2 I c
MOTOR CARR.ID 0 Interstate 0 Intrastate
T - I I I - ❑ Not in Comm./Govt. ❑
Not in Comm./Other0
_ -- - --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'; ❑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
Gray Gray
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG.—CARGO BODY TYPE_LOAD TYPE