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HomeMy WebLinkAbout2025-00080237 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I0110 1111 10 �11111fl 1100 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004076086 u, 1 U21 2 4 1 U1 3 U2 1 U, 1 u2 1 U, 1 U2 1 1 15 U1 1 U2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 14 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash El AMENDED YR 2025I 2025-00080237 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 mST CHARLES ST Elgin 01:43 ® ❑ RELATED ®Y 0 N 12 19 2025 12,— ❑YES ®NO U1 -< _ _ PRIVATE mo !day!yr ®PM FLOW CONDITION RIFT!MI N E S W BENT ST COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 1 (n ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n 0 3 / 13-UNDER CARRIAGE 10 ' 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ ]$I U2 2 rn M 2 4 SYTM❑Y ®SNE❑UNK VEH. O AT CRASH 0 15-99-UUNKNOWN THER9 76•TOP 3 *Distraction Value ALGN X. r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6,_iL 6 4 COM VEH ® 0 1 0 ~ Chicago I L 60629 0 1 0 FIRST CONTACT 12 7 ; _5 *II Yes.See Sidebar Ut Z 9 203706F IL 2026 REAR TELEPHONE IL C 7 1 FD8W3HNXREF08944 Progressive ❑Y ®N U2 63 . m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m Swiatek Inc 970452906 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 21 (,0j m g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMV 0 NCV 0 CIRCLE NUMBER(S) U1 DV Yr !2 0 0 4 Infiniti Q50 2016 00-NONE 0I 2 j-O DUE TO CRASH 0 ❑ 2 x o 13-UNDER CARRIAGE j ©I.( 2 FIRE 0 ® U2 C : F 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOPO3 * X 0 Y NJ 0 UNK VEH. AT CRASH 99-UNKNOWN Oistraellon Value O N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-. 6 iC 4 COM VEH ❑ ® u1 CO FIRST CONTACT 3 7-'_,�_5 •)ryes.See Sidebar = ELGIN IL 60120 0 1 0 ET86270 IL 2026 RFJ IL D 0 J N 1 EV7AR8G M342833 Kemper ❑y 123 N RDEF71 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same 12RA000049696 BAc E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER U1 = (UNIT) (SEAT) (DOBi (SEX) {SAFT) (AIR) (INJI 1(EJCT( (EPTH) PASSENGERS&WITNESS ONLY (NAME)+(ADDRESS)+(TELEPHONE) (EMS) (HOSPITAL) 1 3 06 / ' D / / 1 0 EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 4 12/19 l2025 01 34 ®pm in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 O 2 0 23 28 / / ❑PM ❑Construction Z3 0 1!>I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5 a ® 11 4 ARREST NAME Corral. Hiram.A. 11-601-Ax 482000617 / ! 0 PM SLMT o N 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' ❑AM Utility r 2 ElARREST NAME 12/19 /2025 ❑❑pM El Unknown work zone type , U1 3O T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME El Y 3O 482-Flentcy e.Jeremy 401 - / r ElPM ®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 -< c ` --I -' r INDICATE NORTH combination):or .Z-1 IV BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver _ } (example:shuttle or charter bus):or enrJ,.n..va X 3. Is designed to carry15 or fewer passengers and operated a contract carrier O I- <.__-A-.-.� ATI1719cS I y } } } transportingemployees In thecoursee of their employment ployment(example:employee transporter-usually a van type vehicle or passenger car):or wL L.___a.._.� ooMz it L.... . 4. Is used ordesi natedtotrans transport passengers,including w } } } g po passen rs,includi the driver, wiz "�" r for direct compensation(example:large van used for specific purpose):or L L--_-a-.... - - - r i i m. - - - t i I 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example:placards will be displayed on the vehicle). m,Zt - . 1 _ CARRIER NAME Z ADDRESS 0T. . . . . [ . Not To Scale ( w CITY/STATE/ZIP I 0 MOTOR CARR.ID 0 Interstate 0 Intrastate l I r l ❑ Not in Comm./Govt. 0 Not in Comm./Other ; _Y_ _-1 USDOT NO. ILCC NO. m XI Source of above z . 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 ®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 0 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w White 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: 3 TOWED BY/TO: DUE TO ® Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE