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HomeMy WebLinkAbout2025-00073550 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 10110 ll 1111 10111111 fl 011110 0 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004033019' u, 1 U21 2 4 1 u, 2 U2 1 u, 1 1_12 1 1.11 1 U2 1 1 15 U1 1 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash 0 AMENDED YR 2025I 2025-00073550 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIPINTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n WILDMERE DR El In 04:31 ® 0 RELATED ®Y ❑N 11 14 2025 ❑AM ❑YES ®NO U1 -< g PRIVATE mo !day!yr ®PM FLOW CONDITION m FT!MI N E S W W H I C H LAN D AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 1 (n ❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 0 FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0 0 6 ! yr 13-UNDER CARRIAGE 101 ! 2 FIRE 0 IE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m F 2 SYTHER 6 ❑Y ®SNE❑UNK VEH. 0 AT CRASM IN H 0 99-UNKNOWN 9 76•TOP 3 `Detraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF it �i,4 COM VEH 0 Ea 1 C) F. ELGIN I N I L 60123 0 1 0 FIRST CONTACT 7 O7 _; _-5 *If Yes.See Sidebar U1 0 Z BX88484 IL 2025 REAR TELEPHONE IL D 3N 1 AB7AP7JY299273 Geico ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Elgin Fire Same 6012360811 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER XI Refused 0 Y El 2 0 x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 r uv 0 txv 0 DV CIRCLE NUMBER(S) U1 /1 9 6 4 Honda CRV 2021 00-NONE 0.,. 2 j--_, DUE TO CRASH 0 2 x ... yr 13-UNDER CARRIAGE 9 I ©). 2 FIRE 0 ® U2 C c F 2 5 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracl on Value 0 i1i N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF FIRST CONTACT 12 4 COM VEH ❑ ® 8 7 B .5 • Z Crystal lake IL 60014 0 1 0 DA40321 IL 2026 REAR It Yes.See Sidebar U1 CO 0 N IL D 7FARW2H87ME036453 State Farm ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same 0068967-SFP-13 BAC $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER u1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (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 u 1 ® 11 1 11 ,14 ,2025 04 31 ®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 2 0 2 99 11,14 ,2025 04 31 ®PM ❑Construction R O 0 ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 3 ❑AM 0 Maintenance U2 o1 ® 11 1 ARREST NAME Lampe. Brianna.J. 11-901 S1552000221 11,14 l2025 04 36 ®pM SLMT o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility 0 AM r 2 ❑ ARREST NAME 11,14 ,2025 04 50 0 PM 0 Unknown work zone type U1 4O n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ 1552-Thompson.Ahmad Rashad 602 269-Mendiola 12 , 16,2025 01 30 ®pM Workers present? ®N U2 40 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 truckrtrailer -< c ` -' -' r INDICATE NORTH combination):or -I ' BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver _ } (example:shuttle or charter bus):or < <----- -•-•; - trans tl rtlg em lloyeeslin 5 thr e coursr e of rye r employment example:employct eeder I. F po n9 pemployment w ora�dvue transporter-usually a van type vehicle or passenger car):or 03 i. •-----}----; - - } } 1 •4. Is used or designated to transport between 9 and 15 passengers,including the driver. C 0. 01114 for direct compensation(example:large van used for specific purpose):or O L - - 1 i- Utica L i i _ 5 Is any vehicle used to transport anyhazardous material(HAZMAT)that requires i s placarding(example:placards will be displayed on the vehicle). Xil -- -1 1 0 - ADDRESS CARRIER NAME 'n Z rn Not To Scale CITY/STATE/ZIPn g MOTOR CARR.ID 0 Interstate 0 Intrastate I r ❑ Not in Comm./Govt. 0 Not in Comm./Other ----------1 - USDOT NO. ILCC NO. rn XI Source of above z . 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? ❑ Yes II No ElUnknown A 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 v TRAILER WIDTH(S) 0-96" 97-102" >102' T TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Black 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 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE