HomeMy WebLinkAbout2025-00075607 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 4 Sheets 01111101111
I01101111101001100 I 0
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004045421
u, 9 u21 3 3 2 u1 8 U2 1 U199 U2 1 u1 99 U2 1 2 10 u, 1 U2 3 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00075607 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIPINTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 -n
® 0 RELATED ®Y ❑N 11 25 2025 ®AM ❑YES ®NO U1 —<
BLUFF CITY BLVD Elgin06:13
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FT!MI N E S W ST CHARLES ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 15 Cn
❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 —I
CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 Nuv 0 ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C)
/ / FOR DAMAGEDAREA(S) FRO r TOWED U1 Q
NAME(LAST,FIRST,M) Unknown. Unknown. U. mo yr Unknown Unknown 00-NONE0
13-UNDER CARRIAGE N,•..I 12! 2 DUE TO CRASH 0 EN FIRE 0 ® E
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 2 DISTRACTED 0 0 U2 0 m
9 9 ❑Y ® 15-OTHER
SYSTEM
❑UNK VEH. 0 AT CRASH D 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8_iL a ii,4 COM VEH ® ❑ 1 0
~ Unknown 0 9 0 FIRST CONTACT 1 7_; __5 *I(Yes.See Sidebar Ut
Z UNKNOWN Unknown REAR
TELEPHONE
UNKNOWN UNKNOWN ❑Y 0 N U2 m
IS EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same UNKNOWN 2 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
t 0 Y°®N
/1 9 8 2 Nissan Rogue 2020' 00-NONE O,' t2 "_1 DUE TO CRASH ❑ 2 x
0 13-UNDER CARRIAGE 10 I 2 FIRE ❑ ® U2 C
c
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y ®N DUNK VEH. AT CRASH 99-UNKNOWN *Oistraglon Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 5
FIRST CONTACT 11i1 1i 4 COM VEH ❑ ® U1 CO8 7 _, _5 •IfYes,See Sidebar
— Hanover Park IL 60133 0 1 0 EE34043 IL REAR- 0 C
Z
IL D J N 1 BJ 1 CW2LW649153 STATE FARM ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 1129909SFP13 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
1 0
E/ MOST EVNT LOC, DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 11 ,25 /2025 06 13 ®❑PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
2 ❑ 20 18
N 1 3 ❑ 0 CITATIONS ISSUED 0 PENDING ( 1 ❑PM El Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 3
—a, ARREST NAME / / El PM '
oN ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT
t 2 ❑ 35
AM
7 ❑PM ❑Unknown work zone type U1
cf- ARREST NAME ( / ❑
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ ❑AM Workers present? ❑Y 35
486-Munoz.Jasmine 400 — / / 0 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 truck trailer -<
c ` --I -' r INDICATE NORTH combination):or -I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
_ } (example:shuttle or charter bus):or
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3. Is designed to carry15 or fewer passengers and operated a contract carrier O
A ' 'i uev�rm.a `
i - . - . transporting employee in the course of their employment(example:employee
e a + transporter-usually a van type vehicle or passenger car):or CO
...j 1
L ,,,a� - I. } } 1 •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 O
L — — — —
L i i L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D
_ __ 1 placarding(example:placards will be displayed on the vehicle). XI
s _1
' t CARRIER NAME Z
N ADDRESS D
0 651.16 rn
Not To Scale CITY/STATE/ZIP I
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
-----------1 - USDOT NO. ILCC NO. rn
Xl
Source of above z
. MCS E
❑Yes 0 No 0 Unknown Out of Service ❑Yes ®No
Form Number 0
m
Xl
IDOT PERMIT NO. WIDELOAD'; ❑Yes ®No 2
TRAILER VIN 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
0
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. 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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE