HomeMy WebLinkAbout2025-00001147 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S 1215501-51.500 ®ON SCENE 1
VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
0 AMENDED YR 202512025-00001147 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 mTODD FARM DR Elgin
® ❑ RELATED ❑Y ®N 01 06 2025 ®AM ❑YES ®
PRIVATE NO U1
mo /day/yr 08.01 ❑PM FLOW CONDITION m
_
®10((1 !MI N E O W Todd Farm Dr COUNTY PROPERTY ❑Y ® N DOORING ICIy #OF MOTOR 0 SLOW 2 Cl)
Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS O
Ig:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 NIA/ 0!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0
0 6 /
13-UNDER CARRIAGE 10 ' 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® 0 U2 4 rn
M 2 SY 15-OTHER
4 ❑Y ®SNE❑UNK VEH. O AT CRASM IN H O 99-UNKNOWN 9 76•TOP 3 `Distraction Value 7 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 7 :il a 4 COM VEH 0 gJ 1 0
~ ELGIN I L 60123 0 1 0 FIRST CONTACT 12 7_; _5 *Yves.See Sidebar U1
Z BX98022 IL 2021 Ismi
TELEPHONE
IL D 0 1J8FA24157L190224 All State ❑Y ign4 U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 922888217 4 r
"o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 eu
p; DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑MAv 0 KV ❑ CIRCLE NUMBER(S) U1
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'1 9 6 8 Chevrolet Silverado 2019 00-NONE 11"i 12"- 1 DUE TO CRASH ❑ �I 2
o 13-UNDERCARRIAGE 10;1 2 FIRE ❑ ® U2 C
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP 3 X
❑Y Ni N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraglon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 iII S ..,_4 COM VEH D ® Ut CO
FIRST CONTACT 6 Y__{_O ._5 •(ryes,See Sidebar
= ELGIN IL 60123 B 1 0 AVIATRRB IL 2025 REAR
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IL 0 1GCRYEEDOKZ374731 All State ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Same 811906564 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
KNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
U EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur 0 Y U2 Z
N 1 ® 11 1 11 r 12 ,25 08 01 ❑PM in a Work Zone? ®N DIRP D
co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
0 2 ❑ 41 28 1 1 ❑PM ❑Construction *
R 3 ❑ ZSI CITATIONS ISSUED El PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
a ® 11 1 ARREST NAME Puckett. Edward. L. 11-601 369002196 r r El PM SLMT
124 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility
o N 0 AM 30
r 2 El ARREST NAME Puckett. Edward. L. 6-101 369002195 1 , PM ❑Unknown work zone type U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
369-Varga,John 502 275-Engelke 11 , 71 /025 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
ADDITIONAL UNITS FORMS.
r ----r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and:IZ
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer Z
i- (-- -Y- --; I I ( INDICATE NORTH
combination):or
A
_ 1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
L 0
r r ,. (example:shuttle or charter bus):or X
I •.__J ` 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
i <____a____. Todd9Faim?Dr - } transporting employees In the course of their employment(example:employee P3
— — — — — — } . transporter-usually a van type vehicle or passenger car):or w
L L____a____-: •4. Is used ordesi natedtotrans rtbetween9and15passengers,includingthedriver,
} } } for direct compensation(example:large van used for speific purose):or 0
L L____a____- ® t . .. i 5. Is any vehicle used to transport anyhazardous material(HAZMAT)thatrequires
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placarding(example:placards will be displayed on the vehicle). m
Not To Scete l I >
CARRIER NAME Z
Unk 2
N. va 111
. __ ADDRESS 'n
D
w
CITY/STATE/ZIP 0
0
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I I ❑ Not in Comm./Govt. 0 Not in Comm./Other
---"-4. USDOT NO. ILCC NO. m
I
Source of above z
. If Yes,Name on placard 0
4 digit UN NO. 1 digit Hazard class No. Xl
71
m
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's Z
own tank)? 0 Yes 0 No 0 Unknown D
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes 0 No 0 Unknown M
Did Carrier Safety Regulations I/ICS)violation contribute to the crash?❑ Yes IQNo El Unknown Unknown 0
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
to
LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 0 0 0 Z
4
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Maroon Silver
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 2 TOWED BY/TO.
_Redmons/Impound Lot Garage . 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