HomeMy WebLinkAbout2025-00081176 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
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INVESTIGATING AGENCY DAMAGE TO ANY El 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 3
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
El AMENDED
YR 2025I 2025-00081176 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 m500 S MCLEAN BLVD Elgin03:24
® ❑ RELATED ❑Y ®N 12 25 2025 12,— ❑YES IX]NO U1 -<
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COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
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INVLD ❑ STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
FOR DAMAGEDAREA(S) FROf• tf�TOWED U1 0Ames.Cornellius.A. 1 2 /
yr 13-UNDER CARRIAGE 1U • 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 4 <<n
M 2 4 ❑Y ®SNEM❑ 15-OTHER
UNK VEH. O AT CRASHIND O 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF & i�6 �i 4 COM VEH 0 j$J 1 0
F• Elgin I L 60123 0 1 0 FIRST CONTACT 11 7_: __5 *!ryes.See Sidebar U1
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RESPONDER
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!2 0 0 6 Toyota Camry 2015 00-NONE ,�_ t2 DUE TO CRASH ❑ 2
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N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR A 6
FIRST CONTACT 1 Y _�-`-�•byes,See Sidebar
PINGREE GROVE IL 60140 0 1 0 CL87939 IL 2026REAR C
IL D 0 4T4BF1 FK2FR468899 State Farm ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Devries. Darren.C. 0644774SFP13 BAC
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(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
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EV MOST EVNT LOC, DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 12,25 l2025 03 24 ®pm in a Work Zone? ®N DIRP co
1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 3 n
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2 0 2 06 1 1 ❑PM ❑Construction X
Z 3 0 I!!I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
a ® 11 1 ARREST NAME Ames.Cornellius.A. 11-901 S1526000 / ! El PM SLMT
I$!CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM• ❑Utility
t 2 El ARREST NAME Ames.Cornellius.A. 6-303-A S1526000764 12+25 /2025 04 00 0 PM El Unknown work zone type U1 35
2 23 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 0 qM Workers present? ❑Y 35
1526-Walsh.Jacob 702 269-Mendiola 01 ,27,2026 01 30 ®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 truckrtrailer -<
Fleetwood/Dr ; combination):or
- i•----r----, - r INDICATE NORTH -1
_ _ _ BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ i. e. r (example:shuttle or charter bus):or
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3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
I N . - . transporting employees In the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
i. <____A____� 50M3?Mdeen?Blvd •4. Is used or designated to transport between 9 and 15 passengers,including the dryer, C
I 3TMdwn781vd for direct compensation(example:large van used for specific purpose):or O
< i____a----. 12 I - � i. I 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). XI
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CARRIER NAME Z
I - , __ ' ADDRESS D
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CITY/STATE/ZIP
I _ MOTOR CARR.ID ❑ ta ❑
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;-_---- _-.; - USDOT NO. ILCC NO. m
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Source of above z
. 0 Yes J No ❑ Unknown A
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
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Form Number 0
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Xl
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
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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
Black Black
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 2 TOWED BY/TO.
Arties/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE