HomeMy WebLinkAbout2025-00078234 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II l l 11 II I II Milill 11 ,1011111 H
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY 0$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S 0$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 202512025-00078234 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
SLADE AVE Elgin07:01
® ❑ RELATED ®Y 0 N 12 08 2025 ❑AM ❑YES IX]NO U1 -<
_ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION m
FT l MI N E S W DOUGLAS AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 cn
❑ Kane HIT ❑Y ® N WITH VEHICLES INVLD El STOPPED U2 --I
lgi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) &RUN PEDALCYCLIST IZI N ❑ FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑uuv 0!Cy ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
FOR DAMAGEDAREA(S) FRONT TOWED U1 O
Dorse Alonzo 0 7 /
yr
13-UNDER CARRIAGE
I! FIRE ❑ NI
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED 0 0 U2 2 m
M 2 SY4 ❑Y ❑STM NE N UNK VEH. 9 AT CRASH 9 99-U 15- NKNOWN THER9•16•TOP03 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s• iI B �I COM VEH 0 El 1 n
FFIRST CONTACT 2 7 _ --_;__5 *IIYes.See Sidebar U1 0
V Z Streamwood IL 60107 0 1 0 CZ49080 IL 2025 Tsui
7 TELEPHONE
IL D 0 1 G4PP5SK5D4140013 Lincoln Insurance ❑Y Il N U2 13 . m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same A05505285 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Refused 0 Y El 2 0
p; DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES O NMV 0 NCv ❑DV
!1 9 9 2 Mazda 3 2016 00-NONE O Qj'O DUE TO CRASH El2
o 13-UNDER CARRIAGE I 1 FIRE 0 N U2 C
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F 2 4 SYSTEM IN 9 ENGAGED 9 15-OTHER 9 16-TOP 3
❑Y ❑N ®UNK VEH. AT CRASH 99-UNKNOWN `Oistracnon Value 9 0
POINT OF s i1 0 4 COM VEH 0 N U1 W
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 12 7� J i s *If Yes.See Sidebar
ELGIN IL 60120 0 1 0 Z902155 IL 2026 aR 0 N
IL D 3MZBM 1 W7XG M239910 State Farm ❑Y ®N RDEF M
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 X
Elgin Fire Same 2149714-SFP-13 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (DOBI (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 3 01 / F 9 5 0 1 0
m
/ / #OCCS >
7/
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/ / 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 1 12/81 /025 07 01 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
v 2 0 23 99 12/81 /025 07 O1 ®pM 0 Construction >F
R 1 3 ❑ xi CITATIONS ISSUED ElPENDING SECTION CITATION NO. EMS ARRIVED TIME 3
z J ❑AM ❑Maintenance U2
aEl 11 1 ARREST NAME Dorsey.Alonzo 11-1204-B S1552000244 12/81 /025 07 08 Igi pM SLMT
S' N
1
0 CITATIONS ISSUED ❑
PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • Utility
0 AM
t 2 El ARREST NAME 12/81 /025 07 37 N PM 0 Unknown work zone type U1 3O
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ID1552-Thompson.Ahmad Rashad 102 391-Jacobucci 11 , 01 /025 01 30 ®PM Workers present? ®N U2 30
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
1,04111167Aw 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
c ` -' -' r INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} (example:shuttle or charter bus):or
lir
< <---- -•-•; transporting employeeslin5 thr e coursr es o rhea emaployment example:employeener X
I. } }
transporter-usually a van type vehicle or passenger car):orco
Lj . L 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____. — — unsa I I, _ L i i 5. Is any vehicle used to transport anyhazardous material(HAZMAT)thatrequires
-u
'. — aI 3 — — — placarding(example:placards will be displayed on the vehicle). XI
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— —1
araevay.
ADDRESSCARRIERNAME 'TZ
T.
CND CITY/STATE/ZIPTNof To Scale
t. MOTOR CARR.ID 0 Interstate El Intrastate
I . ❑ Not in Comm./Govt. 0 Not in Comm./Other
----------1 USDOT NO. ILCC NO. m
XI
Source of above z
. If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. XI
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 g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash? A
❑ Yes II El 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 VIM 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 Black
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE