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HomeMy WebLinkAbout2025-00076108 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 1111111111111111 11111111 ,1001100000 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X�06&618 u, 1 u21 3 4 1 u, 4 U2 1 u, 1 1_12 1 u,99 U2 1 1 15 U1 15 U2 1 *P0119* INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 3 VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT) (83B Injury and/or Tow Due To Crash 0 AMENDED YR 202512025-00076108 VENT ADDRESS NO. HIGHWAY or STREET NAME ® ❑CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r7 RT20 RELATED ®Y 0 N 11 27 2025 03:28 ❑AM ❑YES ®NO U1 Elgin PRIVATE mo /day/yr ®PM FLOW CONDITION m FT!MI N E S W SHALES PKWY COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR El SLOW 3 Cl) ❑ Cook HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ® FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!Cy 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 8 0 0 6 / yr 13-UNDER CARRIAGE ©i O! 2 FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O 2 DISTRACTED 0 ]Si U2 8 m M 2 SY5 ❑Y ❑STM NE®UNK VEH. 9 AT CRASH 9 99-U 15-UNKNOWN THER O9 16•TOP 3 *Distraction Value ALGN X. r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ iI 6 �i 4 COM VEH 0 El 1 0 f. FIRST CONTACT 11 7 . ___5 *IlYes.See Sidebar U1 Z Gilberts IL 60136 A 4 0 V295490 IL 2026 ; TELEPHONE IL D 0 2C3CDZL91 N H246630 Progressive ®v ❑N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m Elgin Fire Walsh. Kevin. R. 967939091 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 eu g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 row 0 NCv 0 DV /1 9 8 3 Honda Odyssey 2013 00-NONE „ "'Oj-_, DUE TO CRASH rg ❑ 2 x 0 13-UNDER CARRIAGE FIRE 0 ® U2 C c M 2 5 SYSTEM IN g ENGAGED g 15-OTHER O9 16-TOP 3 X ❑Y ❑N ®UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 g POINT OF s I COM VEH 0 ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 5 1:_ C FIRST CONTACT 11 7 _,r_5 C. IfYes,See Sidebar Hanover Park IL 60133 A 1 0 Q428096 IL 2026 I 0 N IL D SFNRL5H9XDB087749 Progressive ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Elgin Fire Same 997403360 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 < St.Alexius Medical Center RESPONDER u1 = (UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJ) 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 1 3 08 / LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur El U2 Z N 1 ® 11 1 11 ,27 /2025 03 28 ®AM in a Work Zone? ®N DIRP co 1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 2 0 36 1 28 18 11!27 /2025 03 28 PM ® • ❑Construction * en Z 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 ❑AM 0 Maintenance U2 —a, ARREST NAME 11/27/2025 03 33 ®pM o u 1 0 11 1 0 CITATIONS ISSUED ❑PENDING UtilitySLMT o N SECTION CITATION NO. ROAD CLEARANCE TIME AM' 0 45 t 2 0 36 1 ARREST NAME 1 1!27 /2025 09 47 ®PM 0 Unknown work zone type U1 2 2 3 ® 37 3 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 0 AM Workers present? El 45 1552 Thompson.Ahmad Rashad 401 269 Mendiola ! / ❑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 I . 0 ADDITIONAL UNITS FORMS. r r----r----, , i ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z l 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -< } ----_r__--; _ combination):or -I INDICATE NORTH p1 ^., / i N ' BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C J i.Fi _ } (example:shuttle or charter bus):or n a / 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O _ c Z / - ; } } } transportingemployees In the course of their employment pbgeyment(example:employee r rA transporter-usually a van type vehicle or passenger car):or C , t H }---..I.,.. ...I. 'r ,?,;�, } } •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 o L L-- -a-...� --` _ - t l. I I 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m a- - placarding(example:placards will be displayed on the vehicle). XI CARRIER NAME Z ;o ADDRESS 0{'. / // CITY/STATE/ZIP g /// - i. i. i. i. 4. MOTOR CARR.ID 0 Interstate 0 Intrastate 1 r ./ ❑ Not in Comm./Govt. Not in Comm./Other o; _Y_ _ USDOT NO. ILCC NO. m XI Source of above z . 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 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 3 TOWED BY/TO. Arties/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE DUE