HomeMy WebLinkAbout2025-00075506 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004048389*
u, 9 U21 1 1 1 U, 9 U2 1 U1 99 1_12 1 U1 99 U2 1 1 9 U123 U221 *P 0119*
1
INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00075506 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 '1
508 WAVERLY DR Elgin03:18
® ❑ RELATED ❑Y ®N 11 24 2025 ❑AM ❑YES ®NO U1
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ FT/MI NESW Cook HIT ®Y ❑ N WITH VEHICLES INVLD El STOPPED U2 --I
&RUN
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Q83 DRIVER I] PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!Cy 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
/ / FOR DAMAGEDAREA(S) FRONT TOWED U1 O
Unknown.O. Unknown Unknown 00-NONE it.. 12 , OUETOCRASH ❑ EN
NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 10 ! 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 0 m
SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3
9 9 ❑Y ❑N DUNK VEH. AT CRASH ®-UNKNOWN `Distraction Value ALGN
$ 4 COM VEH 0 ZgJ
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _,I[6 !i,_ 1 0
I— 0 9 FIRST CONTACT 99 7_; _5 *II Yes.See Sidebar U1
REAR
2 Z ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1/
NIA ❑Y ❑N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same NIA 1 I-
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y ❑ N 99 0
0 DRIVER X. PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 NMV 0 Ncv 0 DV
!1 9 9 5 Honda CRV 2025 00-NONE 'o,1 t2 c,�2 FIRE DUE O CRASH 0 ® U2 1 C 13-UNDER CARRIAGE
Ti;
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction value 9 g
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 0�'ij- 6 il;, 4 COM VEH ❑ ® u1 CO
C
FIRST CONTACT 7 O7 11__,�_5 •IfYes,See Sidebar
E LG I N IL 60120 0 1 0 FJ48909 IL 2026 REAR 0 Si)
IL D 0 7FARS4H73SE019743 Statefarm insurance ❑Y ®N RDEF M
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
99 9 Same 0913412-SFP-13 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND 0 N U1 =
KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
0 O
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 18 1 11 ,24 l2025 03 18 ®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
57 2 ❑ 30 18
N 3 ❑ 0 CITATIONS ISSUED 0 PENDING • + ! ❑PM• ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 7
—a ARREST NAME / / ❑PM
o u ® 11 ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT
,
AM15
Tr 2 El
/ ❑❑PM ❑Unknown work zone type U1
ARREST NAME
n OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ ❑AM Workers present? ❑Y 15
1 562 Amador.Aidan 201 , / ❑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
^ i ADDITIONAL UNITS FORMS.
r ----r••--, , "EN• . A CMV is defined as any motor vehicle used to transport passengers or property and: Z
Unit 2 111 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
` ` '' -' I- i INDICATE NORTH combination):or .Z-1
%j BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
n Not_T0 Sce/e _ (example:shuttle or charter bus):or 0
T,
L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
} } } transporting employees in the course of their employment(example:employee 73
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 0
L i t i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D
placarding(example:placards will be displayed on the vehicle). ,Zmt
-I
CARRIER NAME Z
ADDRESS 0
w
0
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate ❑ Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
-"--------4 - USDOT NO. ILCC NO. rn
XI
Source of above Z
. -I
Were HAZMAT placards on vehicle? 0 Yes 0 No =
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 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
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 9 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