HomeMy WebLinkAbout2025-00077476 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 6 Sheets 01111101111
0110 1111101 H III 11111011
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X0O4096396
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑550,-5,.500 ®ON SCENE 3
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
❑AMENDED YR 2025I 2025-00077476 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 m® ° RELATED PRIVATE ❑Y ®N 12 04 202512,—AM ❑YES ®NO U1 -<
N STATE ST Elgin mo /day/yr 04:27 ®PM FLOW CONDITION m
05O�F !MI N E O W BIG TIMBER Rd COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 15
Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Ig:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0
0 8 /
yr 13-UNDER CARRIAGE } FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL O4-TOTAL(ALL) O' DISTRACTED ❑ 0U2 4 m
F 3 8 ❑Y ®SNE❑UNK VINEH. 0 ATCRASHD 0 99-UUNKNOWN THER Ole `DistractionVatue 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $,_iL a if.4 COM VEH 0 j$J 1 0
F. FIRST CONTACT 1 7_;—_;_-5 *II yes.see sidebar Ui
Z WEST DUNDEE IL 60118 A 4 0 389DUR IN 2024 REAR
TELEPHONE
IL D 0 3G N KBCRS9LS601548 State Farm ®Y ❑N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
co
Elgin Fire PANNOS. MARGARET. L. 0836402SFP14 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER
2 ou
Eg DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 iiuv 0 i v 0 DV
/1 9 8 4 Toyota RAV4 2015 00-NONE 11_' 12 -_, DUE TO CRASH ❑ C 2
0 13-UNDER CARRIAGE ( 2 FIRE ❑ ® U2 C
c
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y El ElUNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value 2
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 5 S i:; 4 COM VEH ❑ ® U1
CO
FIRST CONTACT 7 O7 -5 •If Yes.See Sidebar
60110 C 1 0 ZV91440 IL 2026 RE0 Si)C
IL D 0 2T3WFREV5FW190478 State Farm ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 2443950-SFP-13 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Sherman RESPONDER
U1 =
(UNIT) (SEAT) (DOBi (SEX) {SAFT) (AIR) (INJI ,(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)+(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
1 3 09 /
LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 o 11 1 12,41 ,025 04 27 0 AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 ® 11 1 50 08 12,41 ,025 04 27 pM
® , ElConstruction >E
" 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM 0 Maintenance U2
-a, ARREST NAME 1 2/41 /025 04 30 ®pM N '
1 ® 11 1 0 CITATIONS ISSUED ❑PENDING UtilitySLMT
o SECTION CITATION NO. ROAD CLEARANCE TIME 0
t 2 El ARREST NAME 1 2 r 41 1025 1 0 00 0 PM El Unknown work zone type U1 3O
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ° 1519-Bae2 a.Guadalupe 501 269-Mendiola / , ❑❑PM Am Workers present? ®N U2 30
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" Uj
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 -<
---------- Bm7rnneerrru 11 - INDICATE NORTH combination):or p0
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- } (example:shuttle or charter bus):or
---- J T,
1 „ i 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I 0
}.__-A-.-.� I II
- y } } } transportingemployees In the course of their employment
pbyment(example:employee
J transporter-usually a van Type vehicle or passenger car):or w
•---------- - } } } 4. Is used or designated to transport been 9 and 15 passengers,incling the driver, N for direct compensation(example:large van used for specific purpose):or
____a....� + i. < i. L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires mi/I'
( placarding(example:placards will be displayed on the vehicle). D
CARRIERNAME
.1 J ADDRESS O
1 Jf V)
J o
+ I CITY/STATE/ZIP
f
J 1 _ i. MOTOR CARR.ID 0 Interstate 0 Intrastate
1 ❑ O
�� r t
. I I .� Not in Comm./Govt. Not in Comm./Other
J ❑ 0
; _Y_ _. N °f° / f - USDOT NO. ILCC NO. m
I XI
Source of above z
. 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?El❑ Yes II No 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
fn
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
White White
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO.
Redmons/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE
DUE