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HomeMy WebLinkAbout2025-00074564 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 10110 ll 11111011111 I 110111 DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANV X004043100* u, 1 U29 1 1 2 U116 U2 1 U, 1 U299 U, 1 U2 1 5 11 U1 1 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 3 VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT) (83B Injury and/or Tow Due To Crash El AMENDED YR 202512025-00074564 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r7 ® ❑ RELATED PRIVATE ®Y 0 N 11 19 2025 DAM ❑YES El NO U1 -< RT20 EB Elgin mo /day/yr 06:38 ®PM FLOW CONDITION ITT 0 5 FT if) N E S © South State St COUNTY PROPERTY ❑Y 21 N DOORING El #OF MOTOR IR SLOW 15 u) Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I 0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0 183 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NOV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n Cuyuch Laynez. Elsa 0 8 / yr 13-UNDER CARRIAGE 10:) 2 , 2 FIRE ❑ al E STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 rn F 2 4 SY❑Y ®SNE❑UNK VEH. O AT CRAS IN H O 15-OTHER 99-UNKNOWN 9 76•TOP 3 `Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 7_iL 6 4 COM VEH 0 j$J 1 O F. Hanover Park IL 60133 0 1 0 FIRST CONTACT 12 7_; __5 *lI yes.See Sidebar U1 Z AS13001 IL 2026 E TELEPHONE IL D 0 3N 1 AB7AP4J L617718 Kemper ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same 12RA000022015 2 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ® N 2 0 p; DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED 0 PEDAL ❑EWES 0 yr 12 _ C 0 13-UNDER CARRIAGE 10 l 2 FIRE ❑ ® U2 C Ti SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR n SYSTEM IN ENGAGED 15-OTHER 9 16•TOP 3 a 9 9 0 Y ❑N ElUNK VEH. AT CRASH 99-UNKNOWN * 0 Oistrac( n Value U1 POINT OF 8 i '4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 6 Y- _©L=s •COMI s.VEH See Sidebar❑ ® C CO ~ 0 9 0 fiFIAR 0 fn M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 UNK ❑Y ❑N RDEF X EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Same UNK BAC $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < RESPONDER❑Y Ui = (UNIT) (SEAT) (DO01 (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS))TELEPHONE) (EMS) (HOSPITAL) 1 6 02 / - D / / 1 0 EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ®Y U2 Z N 1 ® 11 1 11 ,19 /2025 06 38 ®PM in a Work Zone? ❑N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 2 ❑ 28 99 N 3 ❑ CITATIONS ISSUED 0 PENDING + 1 ❑PM• ®Construction >F SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 3 -a, ARREST NAME / / 0 PM " o u ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT 45 r 2 ARREST NAME AM 7 , , ❑❑PM ❑Unknown work zone type U1 El OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ 1515-BellEck.Stacy 701 391-Jacobucci , / ❑❑PM Workers present? ®N U2 45 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 i----r-•--, /// . A CMV is defined as any motor vehicle used to transport passengers or property and: Z 1. Hasa weight rating more than 10,000 pounds(example:truck or truck trailer -< ` ` '- ' I. INDICATE NORTH combinatlon):or BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver - } (example:shuttle or charter bus):or A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier O } } } transporting employees in the course of their employment(example:employee transporter-usually a van type vehicle or passenger car):or CO L •:. __}----; <—Z - } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver, N for direct compensation(example:large van used for specific purpose):or NO To Scale O __ _ i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D placarding(example:placards will be displayed on the vehicle). XI —I CARRIER NAME Z ADDRESS 0 2 w 0CITY/STATElZIP g MOTOR CARR.ID 0 Interstate 0 Intrastate r ; ❑ Not in Comm./Govt. Not in Comm./Other 22i ❑ 0 �I. ------1 - USDOT NO. ILCC NO. C m 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 M 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 to 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. Z Red u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. _Arties/Owners Residence . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 9 TOWED BY/TO: DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE