HomeMy WebLinkAbout2025-00072923 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S 0$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
El AMENDED
YR 202512025-00072923 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 -n
HOPPS RD El In 01:00
® ❑ RELATED ®Y 0 N 11 11 2025 DAM ❑YES ®NO U1 —<
g PRIVATE mo !day!yr ®PM FLOW CONDITION m
FTlMI N E S W UMBDENSTOCK RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 17 cn
❑ Kane HIT&RUN ❑V ® N WITH VEHICLESOT,
INVLD ® STOPPED U2 —I
CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEON. 0 eaves 0 Nuv 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 99 n
!1 9 yr 4 Chrysler Voyager 2021 0-NONE it , DUE TO CRASH ❑
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NAME{LAST,FIRST,M) mo 13-UNDER CARRIAGE 1U1 12! 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 99 m
M 2 4 ❑Y ®N SYSTEM
❑UNK VEH. AT CRASH 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ ij S �i 4 COM VEH 0 Ea 1 n
F. FIRST CONTACT 1 7 _—--_;__5 *II Yes.See Sidebar U1 0
Z SOUTH ELGIN IL 60177 0 1 0 EL78108 IL 2025 IR
TELEPHONE
IL D 0 2C4RC1 DGOMR533022 AMERICAN FAMILY INS. ❑Y ® r
N U2 n'I
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 410403876166 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
t RESPONDER 0
t, 0 DRIVER 0 PARKED 0 DRIVERLESS 0 PED N PEDAL 0 EWES 0 NUV 0 NCv 0 DV
yr 103-UNDE 10' 12 (,_2 FIRED CRASH 0 ® U2 2 73
C
o 13-UNDER CARRIAGE
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M 19 4 SYSTEM IN 0 ENGAGED 0 ®-OTHER 9.1,6•TOP 3 0 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN • •Oistractlon Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8..I�.4 COM VEH ❑ ® U1 CO
FIRST CONTACT 99 7�'REAR
•IfYes.See Sidebar C
Z South Elgin IL 60177 B 2 8 0 Si)
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IL D 318722506803914 NIA 0 Y 0 N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
South Elgin Fire 2 64 2 Same NIA BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Provena St.Joseph RESPOND❑N 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 0 Y U2 Z
N CD 13 4 11 r 11 r2025 01 00 ®pM in a Work Zone? ®N DIRP >
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I I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1
0 T 2 n
2 ❑ 2 99 ! ! ❑PM• El Construction
Z , 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 7
a ZOLLICOFFER. REGINALD 11-906 244-1827 ! ! PM
—, ARREST NAME ❑
ou 1 ® 11 4 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT
r 2 ❑ ARREST NAMEAM
x- T ! / ❑❑PM 0 Unknown work zone type 30
U1
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 0 AM Workers present? ❑Y 30
244-Blomberg. Michael 702 12 ,23 12025 01 30 ®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••--, , 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 truck trailer -<
- }-- _r_ --; ( combination):or
Not To INDICATE NORTH P1
8oele I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
is., _ } (example:shuttle or charter bus):or
0
rwrRs 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier O
- i. } } } transporting employees in the course of their employment(example:employee X
— — — — — — transporter-usually a van type vehicle or passenger car):or w
L L.___a__. 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or O
L L____a____. ace - i i 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
/r m
n(, placarding(example:placards will be displayed on the vehicle). �
MENEME„, 7MMEMEME CARRIER NAME z
gIEi ADDRESS O
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CITY/STATE/ZIP g
1 - i. i. i. MOTOR CARR.ID ElInterstate ElIntrastate
. ; 5 ❑ Not in Comm./Govt. 0 Not in Comm./Other 0
�---------1 I - USDOT NO. ILCC NO. C
m
XI
Source of above z
. ❑ 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
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LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. y
Red Black
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 0 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