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HomeMy WebLinkAbout2025-00080003 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111 IIIIII II II II 10011 10100 0 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X004076120 u, 1 U21 2 4 2 U1 2 U2 1 U1 1 U2 1 U1 1 U2 1 5 10 U, 3 U2 3 .P0119* INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 8 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) El AMENDED ElB Injury and for Tow Due To Crash YR 2025I 2025-00080003 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ® ❑ RELATED ®Y 0 N 12 18 2025 ®AM ❑YES ®NO U1 -< W HIGHLAND AVE Elgin06:58 g PRIVATE mo /day/yr ❑PM FLOW CONDITION m FTlMI N E S W WOODLAND AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLESOT, INVLD DO STOPPED U2 --I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 /83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEON. ❑EWES ❑NOV ❑!CV ❑DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 n FOR DAMAGEDAREA(S) FRONT TOWED U1 Q Lockett. Lar S. 0 7 / yr 13-UNDER CARRIAGE ©,I �.-2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 0 m M 2 SY 15-OTHER 4 ❑Y ®SNE❑UNK VEH. 0 AT CRASM IN H 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 7 it S ii,4 COM VEH 0 j$J 1 0 ELGIN IL 60123 0 1 0 FIRST CONTACT 11 7_; -__5 *IIYes.SeeSidebar U1 Z FM25434 IL 2025 REAR TELEPHONE IL D 0 5NPDH4AE6DH366971 Kemper ❑Y ®N U2 I- 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR co Same 12AU001488077 2 m `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ® N 2 0 m �{ DRIVER ❑ PARKED ❑DRIVERLESS 0 FED ❑PEDAL 0 EWES ❑ uv 0 KCV ❑Dv �y !1 9 9 3 Chevrolet Cruze 2013 00-NONE ,1_' t2.._, DUE TO CRASH ❑ C 2 oYr 13-UNDER CARRIAGE 1U 1 2 FIRE ID ElU2 C c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER O9 16.70P 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistrac)Dn Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF I S i!,_ COM VEH ❑ ® Ut W FIRST CONTACT 8 O7 _, _5 •(ryes.See Sidebar C ELGIN IL 60120 0 1 0 DA99519 IL 2025 I 0 N IL D 0 1 G 1 PF5SBXD7329545 Kemper ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same 12RA000080657 BAG E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER u1 = KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 1 0 E/ MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occAur ❑Y U2 Z co N 1 El 11 4 12,18 l2025 06 58 ®❑pM in a Work Zone? NJ OIRP D 1 IT PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 1 n 0 2 ❑ 28 2 , , ❑PM ❑Construction * R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 ❑AM ❑Maintenance U2 o1 ® 11 4 ARREST NAME Lockett. Larry.S. 11-601 W1556000128 / ! El PM SLMT o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility 30 F 2 ARREST NAME AM T 1 r ❑❑PM 0 Unknown work zone type U1 El n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 15 1556-Sanchez.Jimena 601 397-Jones / , ❑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 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< ` ` "' -' 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 X ••°. • 3. Is designed to carry15 or fewer passengers and operated a contract carrier O } } } transporting employee In the course of their employment(example:employee X ' l mgs+.�»w transporter-usually a van type vehicle or passenger car):or co L -----}----; `tLt - } } } •4. Is used or designated to transport between 9 and 15 assen passengers,including the driver, for direct compensation(example:large van used fors cific purpose):or ` h_""_a_"""i N I Not To Scale 1 } } i. t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires pMcarding(example:placards will be displayed on the vehicle). ,Zmt ^• r I CARRIER NAME +I ADDRESS O 'A. C CITY/STATE/ZIP MOTOR CARR.ID 0 Interstate 0 Intrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other --- --1 - USDOT NO. ILCC NO. m XI Source of above z • m 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 Brown 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