HomeMy WebLinkAbout2025-00076824 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Df 2 Sheets II I 111 IIII
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00076824 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED PRIVATE ❑Y ®N 12 01 2025 12,—AM ❑YES El NO U1 -<
W HIGHLAND AVE Elgin mo /day/yr 07:56 ®PM FLOW CONDITION III
OO 1C.'J!MI NOS W N State St COUNTY PROPERTY ❑Y 21 N DOORING Ely #OF MOTOR 0 SLOW 1 (n
Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 NIAV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 0
FOR DAMAGEDAREA(S) FRO T TOWED EN
U1 0NAME(LAST,FIRST,M) Freedman. Una. M. 1mo 0 / /2 0 0 4 Jeep(after 19680nd Cherokee 2005 00-NONE „ Oi_, DUE TOCRASH ❑
13-UNDER CARRIAGE 10 : 2 FIRE 0 NI E
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 3 <<T1
F 2 SY4 ❑Y ®SNE DUNK VEH. 0 AT CRASH M IN D 0 99-UNKNOWN 9 76•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ iI 6 4 COM VEH 0 j$J 1 0
~ ELGIN N I L 60123 0 1 0 FIRST CONTACT 12 7 ;1 _5 *II Yes.See Sidebar U1
Z DH48279 IL 2026 E
TELEPHONE
IL D 0 1 J4G R48K45C581553 State Farm ❑Y Igl N U2 13 . m
1 3 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
Same 0598497-SFP-13 3 m
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Refused 0 Y El 2 c
x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMV 0 NOV 0 DV
!1 9 8 8 Kia Motors Coi!i5 2025 00-NONE ,t-I 12--_, DUE TO CRASH ❑ C 2
o 13-UNDERCARRIAGE 10;1 2 FIRE ❑ ® U2 C
c
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP
3 X
❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value 9 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 6
FIRST CONTACT 6 7I- 4 COM VEH ❑ ® u1 CO
I_5 •If Yes,See Sidebar C
Z Streamwood IL 60107 0 1 0 FH71225 IL 2026 PEAR 4 N
M
IL D 0 KNAG64J73S5388425 State Farm ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 2019837-SFP-13 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 12/ 11 )025 07 57 ®PM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 0 28 11
N 3 0 0 CITATIONS ISSUED 0 PENDING + ) 0 PM• El Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 7
-a, ARREST NAME / / El PM '
o N ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
SLMT
AM
T 2 ElARREST NAME 12/1) /025 ❑❑PM 0 Unknown work zone type U1 30
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
❑Y 30
1525-Nave.Oscar 601 269-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
ADDITIONAL UNITS FORMS.
r ----r••--, , 0 A CMV is defined as any motor vehicle used to transport passengers or property and: Z
1. Has a weight rating more than 10,000 pounds(example:truck or truck/trailer -
i- -----------1 \ ` Not To Soa1e I } INDICATE combination):or —I
W Is used r designed to transport more than 1 passengers including driver C
NORTH\ BY 2 se or ig ed transpo 5 sse rs' udin the
} \ ` } r\ r (example:shuttle or charter bus):or 0\ +� 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O
} } } transporting employees in the course of their employment(example:employee
\ \ `• _ transporter-usually a van type vehicle or passenger car):or co
L }-----}----; I. } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver, to
for direct compensation(example:large van used for specific purpose):or O
L L____a____� _ t i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
1 placarding(example:placards will be displayed on the vehicle). ;p
_ 2:., ` ,, \ CARRIER NAME Z
\ ` ADDRESS D
\ ` rn
r r -:- -: C‘ \ CITY/STATE/ZIP 00
\ ` `` i. i. i. i. MOTOR CARR.ID 0 Interstate 0 Intrastate �
I I T I \ , ❑ Not in Comm./Govt. Not in Comm./Other
❑ 0
;____Y____, USDOT NO. ILCC NO. m
XI
Source of above 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
Silver Gray
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