HomeMy WebLinkAbout2025-00072043 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004025090
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INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 El ON SCENE 2
VEHICLE/PROPERTY ®OVER 51,500 ®NOT ON SCENE(DESK REPORT)
El AMENDED ElB Injury and for Tow Due To Crash YR 202512025-00072043 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 —n
HOPPS RD Elgin
® ❑ RELATED ®Y 0 N 11 05 2025 ❑AM ❑YES ®NO U1
PRIVATE mo /day/yr 07:00 ®PM FLOW CONDITION m
®10(x.,1 MI NOS W South Randall Rd COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ® STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
18:DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑uuv ❑!Cy ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 0
0 5 /
yr 13-UNDER CARRIAGE 16) 2 ' 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 3 <<T1
M 2 SY4 ❑Y ®SNE DUNK VEH. O AT CRASH M IN D 0 99-UNKNOWN 9 76•TOP 3 *Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ 1 6 �i 4 COM VEH ❑ 0 1 0
I .
ELGIN I L 60123 0 1 0 FIRST CONTACT 2 7 . -_5 *IrYes.See Sidebar U1
ZES26014 IL 2026 isvi
TELEPHONE
IL D 0 4T1 BF3EK2AU061259 Progressive Universal Ins ❑Y ign4 U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 980134726 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Refused El ® N 2 c
N DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑ uv 0 NCv ❑Dv
0 0 0 Hyundai Elantra 2018 00-NONE 'o,1 t2 c,�2 FIRE DUE O CRASH 0 ® U2 2 C
13-UNDER CARRIAGE
Ti;
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOPS X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `0istracl on Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S-it 6 11 COM VEH ❑ ® U1 CO
FIRST CONTACT 5 7 —_,SOS •IT Yes,See Sidebar
Z SOUTH ELGIN IL 60177 0 1 0 CA39460 IL 2027 I 0
D
IL D 0 5NPD84LF3JH362507 Nationwide ❑Y ®N RDEF M
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Brown,Aaron,W. 9112J032574 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONEI (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 11 ,61 )025 09 10 ®❑PM in a Work Zone? ®N DIRP co
1 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 28 99
N 3 0 0 CITATIONS ISSUED El PENDING + ) ❑PM• El Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 7
—a, ARREST NAME / / ID PM '
o N ® 11 1 •
0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility SLMT
T 2 El 45
NAMEAM
x- 7 1 / ❑❑PM 0 Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 45
565-Villagomez, Mireya 702 — r 1 ❑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 -<
` ` --I -' r INDICATE NORTH combination):or .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} I i i. e. r t- (example:shuttle or charter bus):or 0
.i iLOW03----
410® 3. Is designed to carry15 or fewer passengers and operated a contract carrier I O
I- <.__-A-.---: j• - . } } } transporting employees in the course of their employment(example:employee X
(�Jp�rp SC9f� I I z ,� transporter-usually a van type vehicle or passenger car): r CO
L -----------; __ - } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver, N
L ;____a----; r /— �1 J^ �- ~J^ L for tluectco compensation(example:largevan used for specific requires_ mpe n(ex mple spe ific purpose):orO
i 5. Is any vehicle used to transport any hazardous material(HAZMAT)thatequir m
9100116 / pMcarding(example:placards will be displayed on the vehicle). XI
/ / CARRIER NAME Z
/ / ADDRESS 0
/ C
/ C)
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
; _Y_ _-1 - USDOT NO. ILCC NO. 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. Xl
Xl
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 Red
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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE