HomeMy WebLinkAbout2025-00001371 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 0110110
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003650839'
u, 1 U21 1 1 1 u, 8 U2 1 u, 1 1_12 1 u, 1 U2 1 1 11 u, 13 U2 1 *P 0119
INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 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 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
❑AMENDED YR 202512025-00001371 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 —n
ROUTE 20 Elgin
® ❑ RELATED ❑Y ®N 01 07 2025 ®AM El YES ®NO U1
PRIVATE mo /day/yr 07:40 ❑PM FLOW CONDITION M
l�2 COUNTY PROPERTY ❑Y 21N DOORING ❑y #OF MOTOR 0 SLOW 6 (n
- T re NOS W South McLean Blvd WITH VEHICLES INVLD 0 STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑V ® N PEDALCYCLIST®N ® FREE FLOW # LNS 0
183 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0 icy ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) y N 2 n
0 4 /
yr . Q
13-UNDER CARRIAGE �0 i• : 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 14 U2 2 rr1
F 2 4 SYTM❑Y OS NE❑UNK VEH. O ATCRASHD 0 15-99-UUNKNOWN THER916•TOP3 •Distraction Value ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S,_iL S I, 4 COM VEH 0 0 1 0
H I . Pingree IL 60140 C 1 0 FIRST CONTACT 1 7 ; __5 *lIVes.See Sidebar U1
Z 9 EY29976 IL 2025 REAR
TELEPHONE
IL D 0 SYFEPMAE3MP239086 Progressive El ®N U2 I—
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 961709178 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Refused ❑Y ® N 2 XI
g DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 titwi 0 v ❑Dv
$ 1 9 yf 5 Isuzu NPR 2011 00-NONE 11'f t2 (,�2 FIRE DUE O CRASH 0 ® U2 21 C
o 13-UNDER CARRIAGE
c
M 2 4 ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN •t •Oistraci n Value
POINT OF 8 ii l, 4 COM VEH El ❑ Ui CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR &
FIRST CONTACT 7 Q _,�_5 •If Yes,See Sidebar
Z Villa Park IL 60181 0 1 0 169154F IL 2025 REAR
0 N
D
IL D 0 JALC4W162B7005166 Progressive ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
Ace Delivery Solutio 944847158 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (WI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE! (EMS) (HOSPITAL)
2 3 10 /
2 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
u 1 ® 11 1 11 r/2 /25 07 40 ®❑PM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
o"
2 20 28 1 1 ❑PM ❑Construction >F
4
R 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM ❑Maintenance U2
o1 ® 11 1 ARREST NAME Caraway. Halley.A. 11-601 W369002197 r / ❑PM SLMT
o N •
❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility
❑ 55
T 2 El ARREST NAME AM
7 1 r ❑PM ❑Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 55
369-Varga.John 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.
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 ` --I -' 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
. A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
} } } transporting employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
L L.___a__. - 4. Is used or designated to transport between 9 and 15 passengers,including the driver. C
___ i e.... } } } •
for direct compensation(example:large van used for specific purpose):or 0
L___-a-___-I _ ` - t l. I I 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
_ placarding(example:placards will be displayed on the vehicle). XI
dws..r ; D
CARRIER NAME Z
Z
ADDRESS 0
w
CITY/STATE/ZIP I n
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other
�I. --- --1 - USDOT NO. ILCC NO. rn
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 ® 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? A
❑ Yes II El 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 ®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 White
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