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HomeMy WebLinkAbout2025-00081488 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111 )0110 II 1111 100 I 1111I0II DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X 08 3385 u, 9 U21 1 1 1 U199 U216 U,99 u2 1 U199 U2 1 5 11 u, 1 U2 1 *P 0119 INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY 0$500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00081488 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 -n ® ❑ RELATED ' ' 0 N 12 27 2025 ❑AM ❑YES IX]NO U1 -< BIG TIMBER RD Elgin09:03 _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION III E05 ®0 !MI N E S Byron Ln COUNTY PROPERTY ❑Y ® N DOORING ❑Y #OF MOTOR 0 SLOW 15 0) © y Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C) / / FOR DAMAGEDAREA(S) FROM TOWED U1 Q Unknown.0. Unknown Unknown 00-NONE ,, 12 DUE TOCRASH ❑ VI E NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE IE 10 ! 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 !$I U2 2 I'T7 9 9 SYSTEM IN ENGAGED 15-OTHER 9 76-TOP 3 _ ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN 6 I 4 `Distraction Value ALGN r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF iL 6 Ii COM VEH 0 )gJ 1 O ~ Unknown 0 9 0 FIRST CONTACT 1 7_; __5 *uves.See Sidebar IA Z UNKNOWN ' E TELEPHONE UNKNOWN Unknown ❑Y ❑N U2 I— in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Unknown. Unknown Unknown 2 r `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER . Refused RESPONDER X t 99 0 N DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑NMV 0 NCv ❑DV yr!1 9 9 6 FR Chevrolet Tahoe 2024 00-NONE ,�_"j t2 -_, DUE TO CRASH ❑ (S1 2 0 13-UNDER CARRIAGE 10'I ( 2 FIRE 0 ® U2 73 C Ti F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X ❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistrac on Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 . 6 lc COM VEH D ® ut COI— FIRST CONTACT 7 O7 _�L._5 •If Yes,See Sidebar ELGIN IL 60123 0 1 0 EZ27605 IL 2025 REAR0 IL D 0 1GNSKTKL7RR100169 Roamly ❑Y ®N RDEF X EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X 99 9 Same R09440209 BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 < Refused RESPONDER U1 = (UNIT) ISEATI (DOB( (SEX) {SAFT) (AIR) (INJ) 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 2 12 08 / ' D / / 4 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 11 1 12,27 /2025 09 03 ®PM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 2 ❑ 28 99 N 3 0 ❑CITATIONS ISSUED 0 PENDING • + / ❑PM, ❑Construction SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 7 -a, ARREST NAME / / El PM ' o u ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT 45 t 2 ARREST NAME AM 1 / ❑❑PM ❑Unknown work zone type U1 El T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 10 ❑AM Workers present? ❑Y 45 1524 Silva Jose 501 269-Mendiola , / 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 ` -'- ' r INDICATE NORTH combination):or .Z-1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C - } (example:shuttle or charter bus):or X tn... 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier O - ▪ } } } transporting employees in the course of their employment(example:employee X transporter-usually a van type vehicle or passenger car):or w 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y▪ } } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or O L ` i l. I I 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires — - - r r placarding(example:placards will be displayed on the vehicle). XI —1 CARRIER NAME Z avmire.nu ADDRESS 0 w L L _ Mot To Scofa J i i n ""' - _ CITY/STATE/ZIP 0 MOTOR CARR.ID 0 Interstate 0 Intrastate I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other ------- --1 - i i USDOT NO. ILCC NO. rn XI Source of above Z . 0 Yes 0 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 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 Black Gray u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 2 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