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HomeMy WebLinkAbout2025-00073728 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets _ 01111101111 10110 II ,1111 I��H�� ID 11100 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X�035O33 u, 1 u21 1 1 1 U,99 U299 u, 1 u2 1 u,99 U2 99 1 12 u, 18 U218 �K P 9* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY 0 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) El AMENDED ❑ B Injury and f or Tow Due To Crash YR 202512025-00073728 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 �I W HIGHLAND AVE Elgin02:27 ® ❑ RELATED ❑Y ®N 11 15 2025 12,.. ❑YES N NO U1 PRIVATE mo /day/yr ®PM FLOW CONDITION m 1 0 !MI N E S N Crystal Ave COUNTY PROPERTY ❑Y Igl N DOORING ❑y #OF MOTOR ❑SLOW 1 cn ® �' © ry Kane HIT&RUN ❑V ® N WITH VEHICLESOT, INVLD ❑ STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 183 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0 FROPtf TOWED U1 Zimmerman.Susan.J. 0 9 / yr 13-UNDER CARRIAGE fal �•. 2 FIRE ❑ N STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED N 0 U2 2 m F 2 4 El NSNE❑UNK VEH. 0 AT CRASH IN ENGAGED0 99-UUNKNOWN 9 ,6-TOP® `Distraction Value 9 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 ;• i� 6 �I COM VEH 0 El 5 0 ~ ELGIN I L 60120 0 1 0 FIRST CONTACT 3 7 . __5 *II Yes.See Sidebar Ut Z 3029830B IL 2026 iismi z TELEPHONE IL D 0 1 FTER1 FH2MLD01520 Progressive ❑Y Igl N U2 13 . m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same 992689308 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER > Refused 0 Y El 2 0 x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 r uv 0 KCV 0 DV !1 9 yr76 Nissan Altima 2015 00-NONE OI FRt2 c 2 DUEFIR TO CRASH 0 ® U2 C 2 o 13-UNDER CARRIAGE c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 ❑Y ElN ElUNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value 9 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6-it 6 11:,-4 COM VEH 0 N U1 CO FIRST CONTACT 10 7� _.5 •If Yes.See Sidebar ELGIN IL 60123 0 1 0 EP93548 IL 2026 RE 3 ((I) IL D 0 1N4AL3APXFN386825 State Farm ❑Y ®N RDEF M EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X Same 0842628-SFP-13 BAC $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER U1 = KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(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 ,15 /2025 02 37 ®AM 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 C) Fic 2 0 28 18 N 3 0 0 CITATIONS ISSUED 0 PENDING / / 0 PM- El Construction SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 7 —a, ARREST NAME / / ❑PM ' 1 ® 1 1 1 0 CITATIONS ISSUED ❑PENDING • UtilitySLMT o N SECTION CITATION NO. ROAD CLEARANCE TIME 0 r 2 El ARREST NAME 11!15 /2025 03 22 ®PM El Unknown work zone type U1 0 AM 30 x T n OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 30 1525-NavE.Oscar 607 , ❑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 CIO ADDITIONAL UNITS FORMS. r ----r••--, , I 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 -<r__--; Not To Scale ft I ( INDICATE NORTH combination):or —I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C u } (example:shuttle or charter bus):or X L --I-- A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0 e2 } } } transporting employees in the course of their employment(example:employee X Eta"— - J transporter-usually a van type vehicle or passenger car):or L L.___a__ F � •r 4. Is used ordesi natedtotrans rtbetween9and15passengers,includingthedriver. C �; } } i- for direct compensation(example:large van used for speific purose):or O L L--_-a-___� t i i. L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m placarding(example:placards will be displayed on the vehicle). ;p f — r D J - . . . . . CARRIER NAME Z ADDRESS 0 D cCITY/STATE/ZIPn g MOTOR CARR.ID 0 Interstate 0 Intrastate 0 r ; ❑ Not in Comm./Govt. 0 Not in Comm./Other ;_...Y. ._ I - USDOT NO. ILCC NO. m XI Source of above 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 White 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: 1 TOWED BY/TO. DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE