HomeMy WebLinkAbout2025-00076434 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 0110 ll 1111 10110 ll 11000
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004048.330
u, 9 U21 1 1 3 U199 U2 1 u1 99 u2 1 u,99 U2 1 1 13 u, 15 U2 1 �K 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 0 ON SCENE 2
VEHICLE/PROPERTY El OVER$1,500
®NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00076434 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 -n
S STATE ST Elgin 02:15
® ❑ RELATED ❑Y ®N 11 29 2025 ❑AM ❑YES ®NO U1
_ _ g PRIVATE mo !day!yr ®PM FLOW CONDITION m
FT!MI N E S W W CH ICAGO ST COUNTY PROPERTY El ® N DOORING Ely #OF MOTOR 0 SLOW 1 cn
❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD ❑ STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0(CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
/ ! FOR DAMAGEDAREA(S) .FROM TOWED U1 0
Unknown.O. Unknown Unknown 00-NONE „ 12NT , DUE TOCRASH ❑ EN
NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 101 ! 2 FIRE 0 M <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 m
SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3
9 9 ❑Y ❑N ❑UNK VEH. AT CRASH ®-UNKNOWN `Distraction Value ALGN =
$ 4 COM VEH 0 Ea r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF -,I[S !i,_ 1 00
I— 0 9 0 FIRST CONTACT 99 7_; _5 *lIYes.See Sidebar U1
REAR
2 Z ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1)
unknown 0 Y 0 N U2 I-
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
co
ID
Same unknown 3 m
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y El 99 0
g DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED 0 PEDAL 0 EWES 0!My 0 N v El DV
yr 10 1 12 (, 2 FIRE ❑ ® U2 C
0 13-UNDER CARRIAGE
c
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•Top
3 X
❑Y Ni N ❑UNK VEH. AT CRASH 99-UNKNOWN • •Oistraceon Value 9
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-.I�1:,-4 COM VEH D ® U1 CO
FIRST CONTACT OO 7 �.5 •If Yes.See Sidebar
FEAR C
Z Carpentersville IL 60110 0 1 0 DJ75187 IL 2026 0 Si)
D
IL D 5J8YD4H06KL011283 State Farm ❑Y J N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 1384802-SFP-13 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER®N u1 =
KNIT) (SEAT) (DOB) (SEX) {SART) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 9 11 ,29 l2025 03 30 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
2 ❑ 11 99
N 3 ❑ 0 CITATIONS ISSUED 0 PENDING + ! ❑PM• El Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 1
—a, ARREST NAME / / El PM '
o N ® 11 5 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
SLMT
30
T 2 ❑ ARREST NAME AM
7 1 r ❑❑PM ❑Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 El ❑AM Workers present? ❑Y 30
562-Hernaindez. Myra - r ! ❑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 -
i- }-- ''-- --' r- INDICATE NORTH combination):or -I
_ Not TO$C816 l BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} I I �� �� r r r (example:shuttle or charter bus):or C
I- I- --I--•--; - transporting employened to es Inthe course passengers5 or fewer thir emplod yment example:employeener X
} } }
-----}----+ I - • } } } •transporter sed or des gnated to transport betweelly a van type vehicle or n 9 and passengers,15enger r including the driver. C
II f for direct compensation(example:large van used for specific purose):or O
L i.____a____� _ i 5. Is any vehicle used to transport any hazardous material(HAZMAT)thatrequires m
1I;I placarding(example:placards will be displayed on the vehicle). XI
CARRIER NAME Z
ADDRESS
Nits till D
w
c)
CITY/STATE/ZIP g
- i. MOTOR CARR.ID 0 Interstate 0 Intrastate 5
0
I r i I ❑ Not in Comm./Govt. Not in Comm./Other
�------ --1 - USDOT NO. ILCC NO. m
XI
Source of above z
"" IDOT PERMIT NO. WIDELOAD-; ❑Yes 0 No =
TRAILER VIN 1 m
co
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
Black
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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 0 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE