HomeMy WebLinkAbout2025-00001151 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II III H IIII UHI UU 11E11111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00a690833
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ❑$501-51.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00001151 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 7 m
252 ELY ST Elgin08:50
® ❑ RELATED ❑Y ®N 01 06 2025 ®AM ❑YES ®NO U1 -<
_ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 2 to
❑ FT!MI N E S W Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER O 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 2 n
FOR DAMAGEDAREA(S) FRONT TOWED U1 O
NAME(LAST,FIRST,M) mo
/1 9 8 3 Volvo VAH 2021 00-NONE „ 12 i DUE TOCRASH ❑ EN
13-UNDER CARRIAGE 101 ! 2 FIRE ❑ NI
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
M 2 SYTM IN ENGAGE4 ❑Y ®SNE❑UNK VEH. 0 AT CRASHD 0 99-UNKNOWN 9 16•TOP 3 ,Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR
POINT OF s it S �i,4 COM VEH ® ❑ 1 n
m Z OKEMAH OK 74859-7008 0 1 0FIRST CONTACT 7 ®_; __s Yes.See Sidebar u1
C188A1 GA 9999 ' E
TELEPHONE
IL A 7 4V5RC9EH3MN275310 FLORIDA COMMERCIAL AUTO I ❑Y ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
co
PROFICIENT AUTO TRAN KCA2600778 4 m
17
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER en
Refused ❑Y ❑ N 98 0
❑ DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMv 0 NOV 0 DV
yr ��;j t2 c., E FIRE 0 ® U2 1 C
o 13-UNDER CARRIAGE
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN 0 ENGAGED 0 15-OTHER
9.1,6•TOP3 0 ® SPDR n
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `OistractIon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF O" it 4 COM VEH ❑ ® Ut CO
F,,, FIRST CONTACT 8 Q B l't5 •IT Yes.See Sidebar
2836578B IL 2025 I 0 N
M . STATE CLASS COL ID VIN INSURANCE CO. EXPIRED U2 0
1GCHK24K47E538864 STATE FARM ❑Y ®N RDEF73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
MORA.SAUL 2993566SFP13 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOG) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
0 O
E/ MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur El U2Z
N 1 ® 18 1 01 ,06 /2025 08 50 ®❑PM 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 C)
o"
2 11 99 ) ! ❑PM ❑Construction *
Z 3 ❑ 1!>I CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
a WILSON.JOHN. D. 11-601-A w244-1797 / ! PM
-, ARREST NAMEEl
o N ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT
30
T 2 ARREST NAME AM
7 1 r ❑❑PM ❑Unknown work zone type U1
El
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 D ❑AM Workers present? ❑Y 30
244 Blomberg. Michael 701 275-Engelke , ! ❑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.
A CMV is defined as for vehicle used to transportand:
r ----,5-••--, ; any motor passengers or property
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1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
- i.----i-- --; } } } r -, , ; ; , 1, ( INDICATE NORTH combination):or —I
p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ' i 1 , } (example:shuttle or charter bus):or
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3. Is
L L--------- 1 F '---------- J transporting edmployeeslIn5 hecourseeo theire rsmployment exam pal
e:employeener 73} } }
• � . transporter-usually a van type vehicle or passenger car):or 03
F F-----F----, , F F < <--_-a-___� , , , , 4. Is used ordesi nated to trans rt between 9 and 15 passengers,includingC} } for direct compensation(example:large van used for specificpurpose):or [he driver.
Pe ( P 9 Pe or 0
L L---------_.: L L L ...._-..i.____� l. i i • 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). m,Zj
—D7
CARRIER NAME Z
i.
ADDRESS 0
CITY/STATE/ZIP I cn
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other 0
.----4-----4 ; - ; ; , ; :
USDOT NO. ILCC NO. m
XI
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
Z
Form Number 0
m
Xl
IDOT PERMIT NO. WIDELOAD'; ❑Yes ®No 2
TRAILER VIM 1 m
cn
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. Z
White Blackw
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 1 TOWED BY/TO:
SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE 7 LOAD TYPE 5