HomeMy WebLinkAbout2025-00072838 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 011011111011110111111011
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X 027005
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 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 for Tow Due To Crash YR 202512025-00072838 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m
® ❑ RELATED ®Y 0 N 11 10 2025 DAM ❑YES ®NO U1 —<
S STATE ST Elgin08:49
g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W WASH BURN RN ST COUNTY PROPERTY El ® N DOORING Ely #OF MOTOR 0 SLOW 15 u)
❑ Kane HIT ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I
El AT RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI 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 2 C)
! !
FOR DAMAGEDAREA(S) FRO T TOWED U1 Q
NAME(LAST,FIRST,M) Unknown.O. mo yr Unknown Unknown 00-NONE
13-UNDER CARRIAGE „_' Q I 0 DUE TO CRASH ❑
EN E
) 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 0
~ 0 9 0 FIRST CONTACT 1 7_; _5 *IIYes.SeeSidebar U1
REAR
2 Z ' E
M TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1)
unkown 0 v 0 N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same uknown 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
'',3D Y°®N 0
m N DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 N4y 0 i v 0 Dv
!1 9 r 73 Hyundai Santa Fe 2021 00-NONE 1("j 12..-_, DUE TO CRASH ❑ 2 x
0 13-UNDER CARRIAGE 10'( 2 FIRE 0 El U2 C
M 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3
0 Y NJN 0 UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 0
POINT OF S i ' 4 COM VEH ❑ ® u1 W
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR S
FIRST CONTACT 7 O7 ,�_QI._5 •If Yes.See Sidebar
Bensenville IL 60106 0 1 0 EN56488 IL 2025 REAR 0 C
IL B 7 5NMS5DAL1 MH365819 Progressive ❑Y ®N RDEF M
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
99 9 Same 914788997 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 9 11 ,10 /2025 08 49 ®PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 X
2 0 03 99
N 3 0 ❑CITATIONS ISSUED 0 PENDING ( 1 ❑PM• El Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 2
—a, ARREST NAME / / ❑PM '
1 ® 1 1 1 0 CITATIONS ISSUED 0 PENDING • UtilitySLMT
o N SECTION CITATION NO. ROAD CLEARANCE TIME ❑
0 AM
T 2 ElARREST NAME 11,10 12025 09 00 ®PM ElUnknown work zone type U1 30
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ 1528-Rivera. Kevin 701 269-Mendiola ( ! ❑❑PM Workers present? ®N U2 30
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
A 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
i- }-- -'-- --' 1 - r INDICATE NORTH combination):or -I
N BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
_ } (example:shuttle or charter bus):or
3. Is desgned to car 15 otr fewer passengers and operated a contract carrier O
----- I 4
} } } transporting employees in the course oftheir employment cant(example:employee C
transporter-usually a van type vehicle or passenger car):or w
L }-----}----; 1 - } } } •4. Is used or designated to transport between 9 and 1 passengers,including the driver,
J C
for direct compensation(example:large van used fors specific purpose):or to
L i.____a____. / _ i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
ywpq . . . . placarding(example:placards will be displayed on the vehicle). XI
- —I
CARRIER NAME Z
ADDRESS
__i .�.wrra n , r (A o
CITY/STATE/ZIP g
Not To Scale I — MOTOR CARR.ID 0 Interstate 0 Intrastate O
1 I r 1 ❑ Not in Comm./Govt. ❑ Not in Comm./Other
0
; _Y_ __1 - USDOT NO. ILCC NO. rn
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 VIM 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Gray
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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE