HomeMy WebLinkAbout2025-00072133 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II 111 I M 11111111 ,II 1UI III III I III IO
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X�026987'
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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-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 2025I 2025-00072133 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
N LIBERTY ST Elgin 03:57
® ❑ RELATED ®Y 0 N 11 06 2025 12,— ❑YES ®NO U1 '<
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT l MI N E S W JEFFERSON AVE COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 1 (/)❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUCE 0 uuv 0!Cy 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C)
FOR DAMAGED AREA(S) T TOWED U1 Q
NAME(LAST,FIRST,M) mo yr
D urd evic. Malisa Honda Accord 2019 00-NONE ,, • 12 , DUE TOCRASH ® ❑
10
13-UNDERCARRIAGE I! 2 O FIRE 0 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ ]$I U2 m
M 2 8 ❑Y ®N
SYSTEM
❑UNK VEH. O AT CRASH
IN D 0 99-UNKNOWN 9 76•TOP® ,Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $_iL a ii,4 COM VEH 0 j$J 1 0
H 1- HOFFMAN ESTATES IL 60192 0 1 0 FIRST CONTACT 2 r: --s *If Yes.See Sidebar U1
ZBQ27995 IL 2026 REAR
TELEPHONE
IL D 0 1 HGCV2F93KA022881 Acuity Insurance ❑Y Igl N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
co
Elgin Fire 99 9 Same VW9799 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y El 2 0
N DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 iiuv 0 i v 0 Dv
/1 9 9 6 Chevrolet Cruze 2017 00-NONE 0.. Qi'-0 DUE TO CRASH rg ❑ 2
o y yr 13-UNDER CARRIAGE 10) f: 2 FIRE 0 ® U2 C
M 2 8 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 8-iI�1:,-4 COMVEH 0 ® U1 CO
FIRST CONTACT 12 7 _, -5 •If Yes.See Sidebar
= ELGIN IL 60120 0 1 0 BZ56631 IL 2026
IL D 0 1 G1 BE5SM5H7152665 SafeCo Insurance ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire 99 9 Same Z5254284 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER
u1 =
;UNIT) (SEAT) (DOBI (SEX) {SART) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((A.DDRESS)((TELEPHONEI (EMS) (HOSPITAL)
1 4 09 /
7/
/ / UI 3 m
/ / 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 oil 4 11 ,06 /2025 03 57 ®AM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
v 2 0 28 2 11/06 /2025 03 57 ®pM El Construction
>F
R 3 ❑ xi CITATIONS ISSUED ElPENDING SECTION CITATION NO. EMS ARRIVED TIME 1
z J ❑AM ❑Maintenance U2
o ® 11 4 ARREST NAME Djurdjevic. Malisa 11-601 S1542-000523 11/06/2025 03 57 Igi pM SLMT
o N
0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' 0 Utility
0 AM t 2 El ARREST NAME 1 1/06 /2025 04 45 ®PM 0 Unknown work zone type U1 30
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1 542 Chafe. Ethan 201 12 + 16/2025 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.
r ----r••--, , N ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
Has a weight rating more than 10,000 pounds(example:truck or truck/trailer 1 �
} } ' ' I • INDICATE NORTH combination):or -I
Not To Scale 1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} I } r r r (example:shuttle or charter bus):or
A Mil 0-- 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
} } } transporting employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
4. Is used or desi nated to trans rt between 9 and 15 ge including 0Cj)
-- -- } } g po passen rs,includi the driver,
I unk 1 for direct compensation(example:large van used for specific purpose):or o
110-00) } } } t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placartling(example:placards will be displayed on the vehicle). ;p
i. CARRIER NAME Z
Vary 0
ADDRESS
1 i. i. i. i. 4.
CITY/STATE/ZIPg
Ii. MOTOR CARR.ID 0 Interstate El Intrastate
I I T I 4.
❑ Not in Comm./Govt. 0 Not in Comm./Other
I I _ '
I USDOT NO. ILCC NO. m
XI
Source of above z
. MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No 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 Brown
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 DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE