HomeMy WebLinkAbout2025-00078394 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 a2 Sheets 01111101111 I0110 1111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004066589-
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT 0 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 El NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
El AMENDED
YR 202512025-00078394 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
595 S STATE ST El In11:44
® ❑ RELATED ❑Y ®N 12 09 2025 ®AM ❑YES El NO U1
g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
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COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ FT!MI N E S W Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD IN STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
1 0 !
yr 13-UNDER CARRIAGE 1a.I 2 ' 2 FIRE 0 ® <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® 0 U2 m
F 2 4 Y SYSTEM IN ENGAGED 15-OTHER 9 76.TOP 3 7 ALGN =
❑ ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ ;iI 6 4 COM VEH 0 gJ 1 00
F. FIRST CONTACT 12 7. . , _5 *If Yes.See Sidebar U1
Z SOUTH ELGIN IL 60177-1653 0 1 CZ30171 IL 2022 is
TELEPHONE
IL D 1 NXBR32E66Z708453 American Alliance ❑Y ®N U2 13 , m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
Same I LAA-0752038-03 2 m
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 X
N DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL ❑EWES O N4v 0 N v ❑DV
!1 9 9 5 Toyota Corolla 2022 00-NONE ,t"' 12..-_, DUE TO CRASH ❑ C 2 73
o 13-UNDERCARRIAGE ta;l 2 FIRE El El U2 C
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M 2 4 SYSTEM IN ENGAGED 15-OTHER 9 16•TOP 3 0 X
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 iII 6 .. .4 COM VEH ❑ ® Ut W
FIRST CONTACT 6 Y__{_ -5 •IfYes.SeeSidebar
n ELGIN IL 60123 B 1 EZ52383 IL REAR C
0
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IL D SYFEPMAE4NP296754 Progressive ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Same 862846193 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
KNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
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 12,09 l2025 11 44 0 PM AM in a Work Zone? ❑N DIRP >
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1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
0
,
2 0 03 99 , , ❑PM ®Construction >E
Z 3 0 xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
o1 ® 11 1 ARREST NAME Webster. Maya.S. 11-710-A 345000265 ! ! ID PM SLMT
o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
30
r 2 0 ARREST NAME AM
1 r ❑❑
7 PM 0 Unknown work zone type U1
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ®Y 30
345-Gomoll.Geoffrey 701 01 , 13,2026 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.
r ----r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
-:- CIO - combination): r more than pounds(example:truck or truck/trailer 1. Has a weight rating10 000 i -<
INDICATE NORTH o p0
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver n
C
- } (example:shuttle or charter bus):or
X
A ® 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
} } } transporting employees in the course of their employment(example:employee 73
® transporter-usually a van type vehicle or passenger car):or w
L L.___a__._.l 4. Is used ordesi natedtotrans rtbetween9and15passengers,indudingthedrrver,
0 I. } } for direct compensation(examp large van used for speific purose):or 0
L i _ 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). XIum 2 —I
CARRIER NAME ADDRESS
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696?S.?Stet. C)
CITY/STATE/ZIP �
Not To Scale j Unit - i. MOTOR CARR.ID 0 Interstate ❑ Intrastate
I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other
-"--------1 - USDOT NO. ILCC NO. rn
XI
Source of above z
. If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. Xl
Xl
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
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LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Black 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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE