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HomeMy WebLinkAbout2025-00076683 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 0110 1111 1011011 IIII 1100 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004048406 u, 1 U21 1 1 1 U, 4 U2 1 U, 1 U2 1 U1 1 U2 1 1 11 U1 1 U2 1 *P 0 1 1 9* INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 3 VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 B Injury and f or Tow Due To Crash 0 AMENDED YR 202512025-00076683 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ® ❑ RELATED ❑Y ®N 12 01 2025 ®AM ❑YES ®NO U1 -< N STATE ST Elgin08:22 _ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION ITl 0 /MI N E S W 1-90 HwyCOUNTY PROPERTY ❑Y Igl N DOORING ❑y #OF MOTOR 0 SLOW 1 (n ® 0Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS O (8:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 6 n FOR DAMAGEDAREA(S) FRO T TOWED U1 O Massey.Zion. N. 0 5 / yr 13-UNDER CARRIAGE ©,I �:: FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 6 rn F 2 4 ❑Y ®N SYSTEM ❑UNK VEH. AT CRASH D 99-UNKNOWN 9 16•TOP 3 ,Distraction Value ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S, i�S 4 COM VEH ❑ Ea O F. FIRST CONTACT 12 7 ;-, _5 *Yves.See Sidebar U1 Z Carpentersville IL 60110 0 1 0 BX99221 IL 2026 8 TELEPHONE IL D 0 4T1 BF1 FK9FU872731 State Farm ❑Y igi N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same 17096135FP13 4 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER XI Refused ❑Y ® N 2 0 p; DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED 0 PEDAL ❑EWES 0 MAV 0 NOV 0 DV CIRCLE NUMBER(S) U1 Yr!2 O O O FR Toyota Camry 2023 00-NONE 10' t2 2DUE O CRASH 0 ® U2 C 2 o 13-UNDER CARRIAGE (,� FIRE Tio F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X ❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distracion VaIue 3 POINT OF 8 i 4 COM VEH D ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 5 FIRST CONTACT 6 O7 ,�=QOS •It Yes.See Sidebar C Z Schaumburg IL 60194 0 1 0 EA36434 IL 2026 aR3 N D IL D 0 4T1T11AK7PU165431 State Farm ❑Y ®N REEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X 99 9 Same 1682094SFP13 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) 2 3 11 / 2 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 1 12, 1/ l025 08 22 Am in a Work Zone? ®N DIRP co 1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 � 0 2 0 15 99 I ! ❑PM ❑Construction * Z3 0 El CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 5 o1El 11 1 ARREST NAME Massey.Zion. N. 11-1427-H- W1557000143 ! ! El PM SLMT o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility 45 t 2 ARREST NAME AM 7 1 r ❑❑PM El Unknown work zone type U1 El OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 45 1557-Wieske. Nathan 501 , ! ❑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. . O. .. .. , A CMV is defined as any motor vehicle used to transport passengers or property and: Z I. ,r• -, I I INDICATE NORTH 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer } 8! ° comb nation)or r-- -r , r p1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C _ (example:shuttle or charter bus):or Not To Scale X I- . 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 X transporter-usually a van type vehicle or passenger car):or w 4. Is used ordesi natedtotrans transport C } } } g po passengers,including the driver, to for direct compensation(example:large van used for specific purpose):or O \ } } } _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m;p placarding(example:placards will be displayed on the vehicle). N.?Stats?St. 2> CARRIER NAME Z ADDRESS O 'r 'r + i 1 lii . . . . - 0 CITY/STATE/ZIP g t i. i. i. i.1 MOTOR CARR.ID 0 Interstate 0 Intrastate I I . I I I I ❑ Not in Comm./Govt. 0 Not in Comm./Other I. --- --: - USDOT NO. ILCC NO. rn Source of above z . xi 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' T TRAILER 1 ❑ ❑ 0 Z ill TRAILER 2 ❑ 0 ❑ O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Silver Black u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. _Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO: DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE