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HomeMy WebLinkAbout2025-00080341 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 10 Sheets 01111101111 0110 111111111111111111111 DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X004082557 u, 2 U21 1 1 1 U116 U2 1 U, 1 u2 1 U, 1 u2 1 5 11 u1 1 u2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash 0 AMENDED YR 2025I 2025-00080341 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 71 ® ❑ RELATED ®Y 0 N 12 20 2025 ®AM YES ®NO U1 -< N STATE ST Elgin01:29 _ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m FT!MI N E S W SGH I LLER ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 04 n 0 9 / yr 13-UNDER CARRIAGE ©,I •:: FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 04 m F 3 SY4 ❑Y ®SNE❑UNK VEH. O AT CRASM IN H O 99-UNKNOWN 916•TOP 3 `Distraction Value ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�S 4 COM VEH 0 El 1 O ~ ELGIN I L 60120 0 1 0 FIRST CONTACT 12 7 . _5 *it ves.See Sidebar U1 ZEN92336 IL 2026 TELEPHONE IL D 0 1 G 11 C5SA5DF353960 None ❑Y ❑N U2 I' 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m co 99 Same None 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER en Refused ❑Y El 2 0 p; DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 Nov 0 N CIRCLE NUMBER(S) U1 v ❑DV 1 9 9 7 Pontiac G6 2007 13-NONE 'o,I t2 c,�2 FIRE DUE ID CRASH 0 ® U2 2 C o Yr 13-UNDER CARRIAGE c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistraglon Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 5 1 S t. 4 COM VEH ❑ ® Ut CO FIRST CONTACT 6 O7 ,�=Q)OS •Iryes.See Sidebar C ELGIN IL 60120 0 1 0 EM69286 IL 2026aR 0 fp IL D 0 1G2ZH36N774153146 American Alliance ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 Same I LAA-0973836-01 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP .22 Refused RESPONDER u1 = KNIT) (SEAT) (DOB) (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 co 12,20 /2025 01 29 ®❑PM AM in a Work Zone? ®N DIRP D 1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 o" 2 ❑ 19 99 1 1 ❑PM ❑Construction >F Z3 0 DygCITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5 -a, ARREST NAME Sotelo.Amy. B. 12-603 748091 / , ❑PM o U 1 ® 1 1 1 MI CITATIONS ISSUED 0 PENDING - SLMT SECTION CITATION NO. ROAD CLEARANCE TIME AM 0 Utility t 2 Eltel ARREST NAME Soo.Amy. B. 11-601 748090 12/20 r2025 02 00 j PM El Unknown work zone type U1 35 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 35 1521-Vega.Wendy 501 360-Yucaitis 11 , 11 /026 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 I . 0 ADDITIONAL UNITS FORMS. r -- r••--, , ; A CMV is defined as any Helot vehicle used to transport passengers or property and: Z Not To rotate I Z i- N combination):fihtor rating more than 10,000 pounds{ xamp .truck or truckrtrarler 1 L e le T r INDICATE NORTH P3 r BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C - } (example:shuttle or charter bus):or — — — — L 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 X r ISchllbft9t1 transporter-usually a van type vehicle or passenger car):or co --- ----; I. } } 1 •4. Is used or designated to transport between 9 and 15 passengers,including the driver, for direct compensation(example:large van used for specific purpose):or O J t i i _ 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires a placarding(example:placards will be displayed on the vehicle). XI CARRIER NAME —I ADDRESS 0 1 y D n CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate 0 Intrastate I I T I I ❑ Not in CommiGovt. Not in Comm./Other �I. --- --1 - USDOT NO. ILCC NO. rn Source of above z . GVWR/GCWR m 0 <10,000 0 10,000-26,000 0 >26,000 z 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 ❑ 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 v TRAILER WIDTH(S) 0-96" 97-102" >102' m TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Blue Black u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 2 TOWED BY/TO. _Mies/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BYlT6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE