HomeMy WebLinkAbout2025-00076195 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑5501-51,500 ®ON SCENE 1
VEHICLE/PROPERTY ElOVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 202512025-00076195 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH -1
1119 DEEP WOODS DR El 10:26
® ❑ RELATED ❑Y ®N 11 28 2025 ®AM ❑YES ®NO U1 -<
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION MCOUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 99 Cl)
❑ FT/MI NESW Cook HIT ®Y ❑ N WITH VEHICLES INVLD ❑ STOPPED U2 —I
El AT RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
0 DRIVER 0 PARKED ❑DRIVERLESS N PED 0 PEDAL 0 EWES 0 uuv 0 Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
FOR DAMAGEDAREA(S) FROM TOWED U1 O
Andresen. Nathan.J. 0 3 /
yr 13-UNDER CARRIAGE IE
101 ! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 23 U2 2 M
M SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 9 ALGN =
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN S l 4 `Distraction Value
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF L 6 1i COM VEH 0 0 1
0
c Z ELGIN I L 60120 B FIRST CONTACT 00 7_; _5 *II Yes.See Sidebar U1
REAR
TELEPHONE
IL D 0 ❑Y ❑N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
4 50 1 Same 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER
m
N DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED 0 PEDAL 0 EWES 0 NMV 0 KCv ❑DV
/1 9 8 0 Dodge Durango 2025 00-NONE i1_"j Q�,-_, DUE TO CRASH ❑ ® 99 xi
0y Yr 13-UNDER CARRIAGE 19( I FIRE ❑ ® U2 C
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M 9 9SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
D Y ®N El UNK VEH. AT CRASH 99-UNKNOWN `Distraction value 9
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-it 6 1:,-4 COM VEH ❑ ® U1 W
FIRST CONTACT 12 7�. .5 •If Yes.See Sidebar
= ELGIN IL 60120 0 9 0 EZ52480 IL 2025 REAR-5 0
IL D 0 1 C4RDJDG8SC504886 Nationwide ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
Same 9112J065086 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOBI (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 12 1 11 ,28 /2025 10 26 ®❑AM in a Work Zone? ®N o1RP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES Check One below:
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1 C)
v 2 ❑ 18 28 11,28 /2025 10 26 ❑PM ❑Construction *
Z 3 ❑ ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
®AM ❑Maintenance U2
-a ARREST NAME 1 1/28/2025 10 34 ❑pM '
1 12 1 ElUtility
0 CITATIONS ISSUED ❑PENDING SLMT
o, N ®
SECTION CITATION NO. ROAD CLEARANCE TIME t 2 ElARREST NAME 1 1 128 /2025 10 26 MA PMM ElUnknown work zone type U1 0
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 05
1556-Sanchez.Jimena 201 367-Stein , / ❑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
} } De
-- -{- --; .pTlNoodTDr Not To Scale 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
- - } INDICATE NORTH combination):or -<
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- } r (example:shuttle or charter bus):or
' 3. Is designed to carry15 or fewer passengers and operated a contract carrier O
I- �-------•-•; N UnitT1 - } } } transportingemployees in the course of their employment
pbyment(example:employee X
transporter-usually a van type vehicle or passenger car):or co
1119TDrap?Wood?Dr C
i_ ...l. 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for speific purpoe):or river,
71
L -a-___. I - t i 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
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5M
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placarding(example:placards will be displayed on the vehicle). ;D
—1
CARRIER NAME Z
ADDRESS 0
W
C)
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate El Intrastate
0
I r ❑ Not in Comm./Govt. 0 Not in Comm./Other
‘I. - --• - USDOT NO. ILCC NO. m
73
Source of above z
If Yes,Name on placard 0
4 digit UN NO. 1 digit Hazard class No. P3
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 M
D
Did Carrier Safety Regulations MCS)violation contribute to the crash?El❑ Yes II No 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
0
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 0 0 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: 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