HomeMy WebLinkAbout2025-00075549 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II III 11 IIII
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INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S 1215501-$1.500 ❑ON SCENE 8
VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT)
®AMENDED ❑ B Injury and f or Tow Due To Crash YR 202512025-00075549 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
785 RUTH DR El04:50
® ❑ RELATED ❑Y ®N 11 23 2025 ❑AM ❑YES El NO U1 -<
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ FT l MI N E S W Kane HIT&RUN ®Y ❑ N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER O PARKED O DRIVERLESS 0 PED CI PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
0 9 !
yr
Chevrolet Cruze 2018 00-NONE , DUE TO CRASH ❑ EN
11-_ +2 -
13-UNDER CARRIAGE 10l • 2 FIRE 0IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 m
F 9 4 ❑Y IN NEM DUIN ENGAGED NK VEH. O AT CRASH O ®15-OTHER UNKNOWN 9 76•TOP 3 ,Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ iI S .. 4 COM VEH ❑ j$J 1 0
~ ELGIN I N I L 60120 0 1 0 FIRST CONTACT 6 7_;LQ•-5 •II Yes.See Sidebar U1
Z AS46423 IL 2025
TELEPHONE
IL D 0 1 G1 BE5SM3J7190403 State Farm ❑Y ign4 U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
1 99 9 Same 2239835-SFP-13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER 73
73
Refused ❑Y 23N 2 0
p DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMy 0 NCv 0 DV
yr 12 - C
o 13-UNDER CARRIAGE 101 r. 2 FIRE ID El U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN 0 ENGAGED 0 15-OTHER 016.70P 3 ❑ ® SPDR n
❑Y ®N DUNK VEH. AT CRASH 99-UNKNOWN `Oistraellon Value 0 -
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF O I C I. 4 COM VEH ❑ ® U1 CO
F,,, FIRST CONTACT 9 7A—5 ••IfYes,See Sidebar C
ER65175 IL 2026 RE O N
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
1 GKKVRKD3FJ270622 State Farm ❑Y ®N RDEF 7)
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Johnson.Tramare.T. 2408698-SFP-13 BAC
$
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)
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 18 1 11 ,23 l2025 04 50 0 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 �
0 2 ❑ 30 99 , , ❑PNI ❑Construction *
Z 3 ❑ I!!I CITATIONS ISSUED El PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
o ® 11 3 ARREST NAME Hernandez. Kimberly 11-404-A 320-7079 / ! El PM SLMT
o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
30
t 2 ❑ ARREST NAME AM
7 1 r ❑❑PM ❑Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 1 O
320-Cox.Jonathan 502 334-Fries / , ❑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
___ Not To Scale 1. as a weight rating more than 10,000 pounds(example:truck or truck trailer -<
H
r i•---.r- - combination): —I
or
0 INDICATE NORTH
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- (example:shuttle or charter bus):or
X
L A I } 3. Is designed to carry 15 or fewer passengers and operated a contract carrier 0
} } transporting employees in the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or w
L i.-----}----; 0f I - I. } } 1 •4. Is used or designated to transport between 9 and 15 passengers,including the driver, N
for direct compensation(example:large van used for specific purpose):or
t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires -u
placarding(example:placards will be displayed on the vehicle). ,Zmt
�nra CARRIER NAME —1
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r r -1- 1 e 79101ADDRESS 'n
0
CITY/STATE/ZIPg
_ i. i. i. i. MOTOR CARR.ID 0 Interstate 0 Intrastate 5
0
r ; ❑ Not in Comm./Govt. 0 Not in Comm./Other
-"-------1 - USDOT NO. ILCC NO. m
XI
Source of above z
0 Yes II No ❑ Unknown A
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
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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
White White
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