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HomeMy WebLinkAbout2025-00075807 ILLINOIS TRAFFIC CRASH REPORT sheet 1 Df 2 Sheets 01111101111 I01101111 II I l0lII*IIIIIIIIIIII DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV XOD4043110 u, 1 u21 3 4 1 u, 2 U2 1 u, 1 u2 1 u, 1 U2 1 5 10 u1 3 u2 1 *P 0119 INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash 0 AMENDED YR 2025I 2025-00075807 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ® ❑ RELATED ®Y 0 N 11 25 2025 ❑AM ❑YES ®NO U1 -< ST CHARLES ST Elgin 11:37 _ _ g PRIVATE mo !day!yr ®PM FLOW CONDITION m FTlMI N E S W BLUFFCITY BLVD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLESOT, INVLD DO U2 —I Igl AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑UUV ❑!CV ❑DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 FOR DAMAGEDAREA(S) FRO T TOWED U1©1 0 Baines. Dezmani. L. 1 1 / yr 13-UNDER CARRIAGE I ! FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 2 DISTRACTED 0 0 U2 2 m M 2 4 ❑Y ®N SYSTEM ❑UNK VEH. 0 ATCRASHD 0 99-UNKNOWN 9 ,6•TOP 3 `Distraction Value 9 ALGN 2 V. CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S, i�S �i COM VEH 0 j$J 1 0 H F. HANOVER PARK IL 60133 0 1 FIRST CONTACT 11 T_; __s *II Yes.See Sidebar U1 ZDH64481 IL 2026 REAR TELEPHONE IL D WAUG FAFCOG N 113414 Progressive ❑Y I$I N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR Same 941097352 2 m `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ❑ N 2 0 g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑iiuv 0 i v ❑Dv !2 0 0 7 Dodge Caliber 2009 00-NONE Q.1 12 c, 2 DUE TO CRASH rg ® U2 2 73 C o 13-UNDER CARRIAGE c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 X ❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istrac on Value 9 0 S 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF i1 s 1!:_ COM VEH El ® U1 CO FIRST CONTACT 11 7 _,__5 •IfYes,See Sidebar = BARTLETT IL 60103 0 1 EK78635 IL 2026 I 0 IL D 1B3HB48A59D162974 Geico ❑Y ®N RDEF X EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Muro. Michael.A. 6147-02-88-38 BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP u1 = (UNIT) (SEAT) (DM (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) U2 996 r m ##occs y 71 / ,, U1 1 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 4 11 ,25 ,2025 11 37 ®PM AM in a Work Zone? ®N DIRP D co 1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 5 C) T o" 2 ❑ 2 06 + , ❑PM ❑Construction X R 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM ❑Maintenance U2 o ® 11 4 ARREST NAME Baines. Dezmani. L. 11-901-A W1534000394 / ! El PM SLMT El CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM• 0 Utility r 2 ElARREST NAME Baines. Dezmani. L. 11-601-Ax 1534000393 11 r 25 ,2025 11 55 ®PM ❑Unknown work zone type U1 30 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 30 1534-Santiago.Jorge 401 12 , 16,2025 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•---, , - ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z (:; ,.,,.o m.—i ; 1. Hasa weight rating more than 10,000 pounds(example:truck or truck trailer c ` --I -' r INDICATE NORTH combination):or -I Ililt 1 BY ARROW (example:used h designedr r transport b more than 15 C passengers including the driver C) } 1 r r r shuttle or charter bus):or 3. Is desgned to carry 15 or fewer passengers and operated by a contract corner O } -A-.-.� } } } transporting employees In the course of their employment(example:employee rter- enger or CO L L.___a____. Q 4 1 } 4aIsuosedordesgnatedtotranslly a van type portbetweeicle or n9a d15rpassen rs,includingthedriver, C 1 } } for direct compensation(examp large van used for specific purpose):or N L ..i.. . \ i. 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m \% placartling(example:placards will be displayed on the vehicle). I1 _ CARRIER NAME Z a~ -- �`L- - __ ADDRESS D to C) , CITY/STATEJZIP MOTOR CARR.ID ❑ tae ❑ 1 I r 11 \\\ ❑ NotInters in Ctomm.lGaA. Not inIntrastate Comm.lOther 0 ‘I. - '-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? 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 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 Silver u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. Arties/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE