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HomeMy WebLinkAbout2025-00073726 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I0110 1111 Ifllfl ll fl VOl 00 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004033013 u, 1 U21 1 1 1 u, 2 U2 1 U111 U2 1 U, 1 u2 99 1 1 U1 1 U299 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 17 VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT) El B Injury and f or Tow Due To Crash 0 AMENDED YR 202512025-00073726 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 m1328 BRUNSWICK CT Elgin02:07 ® ❑ RELATED ❑Y ®N 11 15 2025 ❑AM ❑YES ®NO U1 -< _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 99 Cl) ❑ FT/MI NESW Kane HIT&RUN ❑Y ® N WITH VEHICLESOT, INVLD ❑ STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 Q83 DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES ❑uuv ❑!CV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 1 n 0 2 ! yr 13-UNDER CARRIAGE © I!. 2 FIRE 0 IE < STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED ❑ 0 U2 m M 2 SY 15-OTHER 4 ❑Y ®SNE❑UNK VEH. O AT CRASIN H 0 99-UNKNOWN 916•TOP 3 `Distraction Value ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s,;i�s 4 COM VEH 0 j$J 4 0 ~ ELGIN I L 60120 0 1 0 FIRST CONTACT 10 7 ; _5 *II Yes.See Sidebar U1 Z CZ40094 IL 2026 REAR TELEPHONE IL D 1 FMCUOGX3GUA83278 PROGRESSIVE ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same 975740587 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ❑ N 2 0 0 DRIVER 0 PARKED 0 DRIVERLESS El PED 0 PEDAL 0 EWES 0 N4y 0 i v 0 Dv /1 9 6 8 Other Other 00-NONE 1("j t2'-_, DUE TO CRASH ❑ ® 99 xi 0 13-UNDER CARRIAGE t9 2 FIRE 0 ® U2 C c M 1 3 ❑Y El IN ENGAGED 15-OTHER 9 16-TOP 3 0 X ❑N UNK VEH. AT CRASH 99-UNKNOWN *OistracI n Value N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s-il 6 I1: M ❑ NI U1 CO FIRST CONTACT 15 7��� . C5 •ICOryes.VEH See Sidebar H ELGIN IL 60120 B 1 0 0 Si) M IL D none ❑Y ❑N RDEF71 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Elgin Fire 1 47 1 Same none SAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < St.Alexius Medical Center RESPONDER U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z u 1 ® 12 1 11 ,15 /2025 02 07 ®AM in a Work Zone? ®N DIRP co I I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C) 0 2 14 99 I ! 0 PM ❑Construction * R 3 ❑ 1!>I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 99 ❑AM ❑Maintenance U2 a1 ® 12 1 ARREST NAME Ray.William. R. 11-1008 246 / ! El PM o N • 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility AM SLMT r 2 ❑ ARREST NAME 11 115 l2025 ❑❑PM ❑Unknown work zone type U1 15 n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y 2 2 3 ❑ ❑AM Workers present? ❑ 1535 Solis• Laura 301 269-Mendiola / ❑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 truckrtrailer -< ` ` --I -' r INDICATE NORTH combination):or —I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } - r (example:shuttle or charter bus):or 0 lkill ned to 5 or fewer ers d ` ` _A____, ❑ roamsow_ - transporting mployeeslin hecourse o their employment example:employeener X ):or i. -----}----l. - , } I- 1 •transporter sed or des gnated to transport betweelly a van type vehicle or n 9 and passengers,15enger r including the driver, . CO C for direct compensation(example:large van used for specific purose):or � —r . ._ 5. Is anyvehicle used to transport anyhazardous material(HAZMAT)thatrequires rn ' placarding(example:placards will be displayed on the vehicle). ;p __ D I' CARRIER NAME Z '' O / ADDRESS \ VV) C) CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate 0 Intrastate 0 I . ❑ Not in Comm./Govt. 0 Not in Comm./Other ; _Y- --1 - USDOT NO. ILCC NO. m XI Source of above z . • m 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?El❑ Yes II No 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 Black u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO: _ SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 9 TOWED BY/TO. DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE