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HomeMy WebLinkAbout2025-00078418 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets III 11 IIII UHI U� I� ,IIHIM 1101000 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X 0.9816 u, 9 u21 2 4 1 U, 9 U2 1 U,99 U2 1 U199 U2 1 1 18 U199 u211 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S 0$501-$1.500 ®ON SCENE 14 VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00078418 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m ® ❑ RELATED PRIVATE ®Y 0 N 12 09 2025 ❑AM ❑YES El NO U1 —< S GIFFORD ST1 DIVISON ST Elgin mo /day/yr 02:17 ®PM FLOW CONDITION m 010 ®!MI N E S © S GIFFORD STI DIVISON ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR IR SLOW 1 (n Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 -I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 183 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 / FOR DAMAGEDAREA(S) FROM TOWED U1 0 Unknown Unknown Unknown 00-NONE it.. 12 , OUETOCRASH ❑ EN NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 10 IE !!. 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 9 9 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN a 4 `Distraction Value ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF ilnii COM VEH 0 E! 1 0 ~ 0 9 0 FIRST CONTACT 6 7_:mai _5 *Irves.See Sidebar U1 0 2 Z ' E TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 11/ unknown ❑Y ❑N U2 I— in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same unknown 1 rn `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER r RESPONDER® 0 m N DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 Nuv 0 NCv 0 Dv 1 9 y 8 2 Nissan Rogue 2013 00-NONE 1("1 QI O DUE TO CRASH ❑ 2 73 0 13-UNDER CARRIAGE 10( l 2 FIRE ❑ El U2 C Ti M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s FIRST CONTACT 12 7�-il 6 I1:, 4 5 C(OMry es.VEH See Sidebar❑ NI U1 CO• H ELGINZ IL 60120 0 1 EW61732 IL 2026 REAR . M IL D JN8AS5MT6DW506861 Kemper ❑y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same 12ra00006835 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER U1 = (UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJ) (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) DAMco AGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 11 1 12,09 /2025 02 17 ®PM AM in a Work Zone? ®N DIRP D 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 0 57 2 30 99 N 3 0 0 CITATIONS ISSUED 0 PENDING + / ❑PM• ❑Construction SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 7 —a, ARREST NAME / / ❑PM ' 1 ® 1 1 1 ❑CITATIONS ISSUED ❑PENDING SLMT o N SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utilit y T 2 ❑ ARREST NAME 12 t 15 r2025 02 17 ®PM 0 Unknown work zone type U1 0 AM 30 n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 30 1535 Solis• Laura 307 269-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••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z r jai 1. Hasor thanpound (example:truck or truck/trailer 1. Hasaweightrating more10,000 5 � -< r�r INDICATE NORTH combination): p3 ii 4 N® BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C _ I. (example:shuttle or charter bus):or X I r _ ewt m sow ; 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier O 1 I g _ } } } transporting employees In the course of their employment(example:employee X las i I transporter-usually a van type vehicle or passenger car):or w L L____a.. 4. Is used ordesi natedtotrans rt between 9 and 15 passengers,including C} } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or O L i t i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m placarding(example:placards will be displayed on the vehicle). XI —1 CARRIER NAME1 r Z ADDRESS 'n C) - CITY/STATE/ZI g T. 0 MOTOR CARR.P ID 0 Interstate El Intrastate I I T I ❑ Not in Comm./Govt. Not in Comm./Other ;____Y_._.; USDOT NO. ILCC NO. m XI Source of above z . —I Were HAZMAT placards on vehicle? 0 Yes 0 No = 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 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 Gold u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: g 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