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HomeMy WebLinkAbout2025-00076768 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I0110 1111 1001 Ifl IIIIIOU11ID DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X�050021 u, 1 U21 1 1 3 U, 1 U2 1 U, 1 1_12 1 U,99 U2 1 1 11 U1 1 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El$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 2 VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00076768 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 '1 ® ❑ RELATED ®Y 0 N 12 01 2025 DAM ❑YES ®NO U1 -< WEST BARTLETT RD Elgin03:33 g PRIVATE mo /day/yr ®PM FLOW CONDITION m FT!MI N E S W BEN N I NGTON LN COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR NI SLOW 15 u) ❑ Cook HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 —I CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0 g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUCE 0 NOV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 1 n 1 0 / yr 13-UNDER CARRIAGE ©,I �:: FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14--UNKNOWN (ALL) DISTRACTED 0 ]$I U2 1 r<r1 M 2 THER 4 ❑Y ®SYSNEM IN ENGAGED DUNK VEH. 0 AT CRASH 0 99-UNKNOWN 9 76-TOP 3 ,Distraction Value 9 ALGN = T. 6 COM VEH 0 0 1 CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR ~ POINT OF s,FIRST CONTACT 12 7 i;t 4 0 H 60110 0 1 0 DW70328 IL Isui- __5 •If Yes.See Sidebar U1 c Z E TELEPHONE IL D 0 1 G 1 PC5SBOD7264696 Progressive ❑v ®N U2 I— in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same 991324131 3 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ® N 2 0 g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NAV 0 NOV 0 Dv 96 8 Yr Honda HR-V 2021 00-NONE 11 j 12 , DUE TO CRASH p 2 0 13-UNDER CARRIAGE 10 i I z FIRE 0 ® U2 C F 2 4 ❑Y SYSTEM IN 0 ENGAGED 0 ®-OTHER 9,16-TOP 3 9 0 X i N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistracton Value POINT OF s i 4 COM VEH D ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6 FIRST CONTACT 6 O7 ,�_QI_5 •It Yes.See Sidebar BARTLETT IL 60103 0 1 0 Z427568 IL 2025 REAR 0 C IL D 0 3HGGK5H86FM768704 Allstate ❑Y ®N RDEF71 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Same 922635973 BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z u 1 ® 11 1 12( 11 )025 03 33 ®pM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C) 0 2 ❑ 03 28 / / ❑PM ❑Construction * R 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 U2 -a, ARREST NAME Weiby.Joshua. D. 11-601 485-381 / ( ❑❑PM ❑Maintenance SLMT® 1 1 1 0 • CITATIONS ISSUED PENDING MT o NSECTION CITATION NO. ROAD CLEARANCE TIME ❑Utilit y❑ 0 AM r 2 ❑ ARREST NAME 12 1 11 1025 04 33 ®PM ❑Unknown work zone type U1 25 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? D Y 25 485-Quintana.Josue 401 21 , 12 (26 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. A CMV is defined asmotor vehicle used to transportand: r ----,5-••--, ; any passengers or property Z 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< } i.-- -i-- --; ; } } } i- -, , ; ; , 1, ( INDICATE NORTH combination):or —I P1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } ' i I , } (example:shuttle or charter bus):or X 3. Is L L.-_------ 1 <-- . -___� J transporting employened to es Inhecourse 5 or fewer o their eers mplod yment example:employeener X } } } transporter-usually a van type vehicle or passenger car):or c0 < <.__-a-_-_- , l• < <--_-a-___� . , , , 4. Is used ordesi nated to trans rt between 9 and 15 passengers,including C} } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or 0 L L---------_.: L L L ...._-..:__ ; t i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example:placards will be displayed on the vehicle). m,Zt CARRIER NAME Z ADDRESS 0 T. , n CITY/STATE/ZIP MOTOR CARR.ID 0 Interstate 0 Intrastate 0 ❑ Not in Comm./Govt. ❑ Not in Comm./Other 0 USDOT NO. ILCC NO. m 73 Source of above z . 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 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 Gray u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO: _ SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO. DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE