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HomeMy WebLinkAbout2025-00075984 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II I 111 IIII UHI 1111111111111111111111111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV *X004049912* u, 9 u21 1 1 1 u,99 Uz16 u1 99 u2 1 Ill 99 U2 1 1 12 u, 1 U2 1 *P 0119�K INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ❑ON SCENE 1 VEHICLE/PROPERTY ®OVER$1,500 ®NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00075984 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 —n ® ❑ RELATED PRIVATE ❑Y ®N 11 26 2025 ❑AM ❑YES ®NO U1 —< RT20 WB Elgin mo /day/yr 04:05 ®PM FLOW CONDITION m �0(yO © COUNTY PROPERTY ElY ® N DOORING ❑y #OF MOTOR 0 SLOW 15 Co !MI N E s Grace St WITH VEHICLES INVLD 0 STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN IZ Y ElN PEDALCYCLIST®N ® FREE FLOW # LNS 0 (i DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n / / FOR DAMAGEDAREA(S) 13300ff TOWED U1 Q Unknown.O. Unknown Unknown 00-NONE 11_, 12 , OUETOCRASH ❑ EN NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE IE 10 ! 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® 0 U2 2 m SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 9 9 ❑Y ❑N ❑UNK VEH. AT CRASH ®-UNKNOWN `Distraction value 9 ALGN = a 4 COM VEH 0 ZgJ r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _,I[a !i,_ 1 0 ~ 0 9 0 FIRST CONTACT 99 7_; _5 *IIYes.See Sidebar U1 REAR 2 Z ' E TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1/ NIA ❑Y ❑N U2 m 13 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 > Refused ❑Y ❑ N 99 x DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED 0 PEDAL 0 EWES 0 yr 12 o 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 NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istraebon Value g g s iI 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF --16 COM VEH D ® U1 CO FIRST CONTACT 1 Y�.j_,__5 •(ryes,See Sidebar C Hampshire IL 60140 0 1 0 32075CP TN 2026 REAR g Sn IL D 3GNAXFEV5NS232768 ACE American Insurance ❑Y ®N RDEF X EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Mckee Foods Corporat ISA H11378699 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) U2 996 m ##occs y 71 / ,, U1 1 D 1 0 E/ MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ®Y U2 Z N 1 ® 11 1 11 /26 /2025 05 06 ®AM in a Work Zone? ❑N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C) 2 ❑ 15 18 N 3 ❑ CITATIONS ISSUED 0 PENDING + ) ❑PM• El Construction SECTION CITATION NO. EMS ARRIVED TIME 7 ❑AM ❑Maintenance U2 —a ARREST NAME / / ❑PM ' o N ® 11 1 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT , t 2 ❑ 55 AM x- 7 / / ❑❑PM ❑Unknown work zone type U1 ARREST NAME n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 560-Martirez.Samantha 401 269-Mendiola / / ❑❑PM Am Workers present? ®N U2 45 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••--, , I e N 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 -< 1 IINDICATE NORTH BY ARROW combination):or 2 Is used or designed to transport more than 15 passengers including the driver C } I } (example:shuttle or charter bus):or 0 , 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 i transporter-usually a van type vehicle or passenger car):or w L I I. 4. Is used or designated to transport between 9 and 15 passengers,including C}-----}----; } } } g po passen rs,includi the driver, for direct compensation(example:large van used for specific purpose):or O L i.____a____. I _ l. i. 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). m XI Not To Scale II CARRIER NAME Z ADDRESS 0 w \ CITY/STATE/ZIP g ' i.\4-'' - MOTOR CARR.ID 0 Interstate 0 Intrastate ± I I I �� ❑ Not in Comm./Govt. Not in Comm./Other 00 Y USDOT NO. ILCC NO. <m XI Source of above z . IDOT PERMIT NO. WIDELOAD-; ❑Yes 0 No 2 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 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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO. DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE