HomeMy WebLinkAbout2025-00075983 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 4 Sheets 01111101111 I0110
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004049908
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INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
❑AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00075983 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
SOUTH ST Elgin 04:55
® ❑ RELATED ❑Y ®N 11 26 2025 ❑AM YES ®NO U1 -<
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W S ALFRED AVE COUNTY PROPERTY ❑Y ® N DOORING ICIy #OF MOTOR 0 SLOW 1 cn
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ® STOPPED U2 --I
E j AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) y N 2 n
FOR DAMAGEDAREA(S) FROf tf�TOWED U1 I�
Johnson.Susan.A. 1 2 /
yr 13-UNDER CARRIAGE 10.I 2 FIRE 0 DI
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL)THERDISTRACTED 0 0 U2 2 m
F 2 SYTM 4 ❑Y ®SNE DUNK VEH. O AT CRASH 0 15-99-UNKNOWN 9 16•TOP 3 `Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s it a 4 COM VEH 0 j$J 1 0
~ DEKALB IL 60115 0 1 0 FIRST CONTACT 12 7_;1 __5 *IIYes.See Sidebar U1
Z H173933 IL 2026 REAR
TELEPHONE
IL D 0 4T1 BF1 FK9EU791825 STATE FARM ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 JOHNSON. MARK.A. 1968387-SFP-13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 As
g DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑Nuy 0 i v ❑Dv
/1 9 7 3 Nissan Altima 2013 00-NONE 11 " OI O DUE TO CRASH ❑ (� 2
0 13-UNDER CARRIAGE 10 I. 2 FIRE ❑ ® U2 C
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP 3 X
❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istraglon Value D 9 ® U1 0 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 ,I 6 I. 4 COM VEH
FIRST CONTACT 15 4__{=DLO•If Yes See Sidebar
ELGIN IL 60123 0 1 0 9628584 IL 2025 AR0
IL D 0 1 N4AL3APODN482718 FARMERS INSURANCE ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER I =
99 9 Same 545624341 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER
u1 =
(UNIT) (SEAT) (DOE)1 (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 6 05 / F 2 4 0 1 0
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/ / #OCCS D
71
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/ / 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 11 ,26 /2025 04 55 ®AM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
o"
2 ❑ 28 99 / / 0 PM• ❑Construction *
" 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM ❑Maintenance U2
o1 ® 11 1 ARREST NAME Johnson.Susan.A. 11-601 1551000255 / / El PM SLMT
o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
0 AM
' 2 ❑ 11 1 ARREST NAME 11/26 /2025 04 55 ®PM ❑Unknown work zone type U1 35
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 35
1551-Dede.Joseph 701 269-Mendiola 1/ , 3/ /026 09 00 ❑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 truckrtrailer -<
c ` '' -' I. INDICATE NORTH combination):or .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
N _ (example:shuttle or charter bus):or C)
i
A Not To �� 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I 0
} } } transporting employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
L L.___a____J .a: } C
4. Is used or designated natedtotrans rtbetween9and15 passengers,rs,includingthedriver,
I I I } } for direct compensation(example:large van used for specific purpose):or
A-
I
_+ < . < 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). 71
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— — — —,u..,_,,r�, uumsp— — CARRIER NAME Z
__ ADDRESS 0�1 D
CITY/STATE/ZIP n
il
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
I"--- ----4. - USDOT NO. ILCC NO. m
Xl
Source of above z
. Form Number m
Xl
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
a
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 White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 2 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE