HomeMy WebLinkAbout2025-00003434 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets MI1111111111111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00a6D8152
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ❑5501-51,500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER 61,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 2025I 2025-00003434 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 —n
® ❑ RELATED ®Y 0 N 01 16 2025 ®AM ❑YES ®NO U1 -<
S LIBERTY ST Elgin06:53
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION Ill
FT!MI N E S W MAY ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 15 u)
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
I83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑NIAV ❑!CV ❑DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
FROrff TOWED U1 O
Krueger, Derek.S. Tesla Model 3 2023 00-NONE „ t2 , DUE TO CRASH ❑ EN
NAME{LAST,FIRST,M) g mo yr 13-UNDER CARRIAGE 10l •�. 2 FIRE 0 N
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 4 M
M 2 4 SYTM❑Y NSNE❑UNK VEH. O AT CRASH 0 99-U 15- NKNOWN THER9 16•TOP® ,Distraction Value 9 ALGN X.
fr. CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s• iI �I COM VEH 0 Ea 1 n
F. FIRST CONTACT 4 7 _ s--_;__5 *IIYes.See Sidebar U1 0
Z Bartlett IL 60103 0 1 0 FP195971 IL 2025 "s
TELEPHONE
IL D 0 5YJ3E1 EA5PF451281 Progressive ❑Y Igl N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 1 99 9 Hertz, Mindy 989638246 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER
3 X
p; DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑NOV 0 Ncv ❑DV
!1 9 yf 6 Honda Pilot 2005 00-NONE 0-1 QI'-O DUE TO CRASH rg ❑ 2 73
o 13-UNDER CARRIAGE 10 I !. 2 FIRE 0 N U2 C
M 2 8 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istrac on Value 9 g
POINT OF 8 i1�.-4 COM VEH ❑ N U1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 12 7� B .5 •(ryes,See Sidebar
ZSleepy Hollow IL 60118 B 1 0 DD38503 IL 2025 I g Sn
Z
IL 0 SFNYF185X5B031644 State Farm ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire 1 99 9 Judd, Erika 0900909sfp-13 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE;ZIP
u1 =
;UNIT? (SEAT) (DOE) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
2 4 07 /
:A
/ / UI 1 D
/ / 3 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 4 Pizano. Irvin 555 S. Liberty(home) 11 ,61 ,025 06 53 ®❑pM AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 30
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
v 2 ❑ 555 S LIBERTY BERTY ST ELGIN IL 60120 2 18 1 1 ❑PM ❑Construction >F
Z3 ❑ N CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 1
a ® 11 4 ARREST NAME Krueger. Derek, S. 11-901-A 324-1432 / / El PM SLMT
o 35
N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility
t 2 ❑ 42 2 ARREST NAMEAM
7 / ! ❑❑PM ❑Unknown work zone type U1
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 35
324-Phillos,James 401 21 / 11 ,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: Z
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
} }__-_r_-__1 ! combination)or
INDICATE NORTH
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
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n
} } �71.1berl - r r ,. (example:shuttle or charter bus):or X
u�ro
3. Is designed to carry15 or fewer passengers and operated a contract carrier 0
I- <.__-A-.-.� ti 4110,
- y } } } transportingemployees In the course of their ern pbyment(example:employee
,y*i paw transporter-usually a van type vehicle or passenger car):or CO
Way
L -----}----+ ./. �' - } } 1. •4. Is used or designated to transport between 9 and 15 passengers,including the driver. C
' for direct compensation(example:large van used for specific purpose):or
_a uak 1 - l. i. < . ,_ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
i • placarding(example:placards will be displayed on the vehicle). ;p
Mort l mg CARRIER NAME Z
I I 0ADDRESS
tiwb r
oaro , • , • ,
CITY/STATE/ZIP C)O
MOTOR CARR.ID 0 Interstate 0 Intrastate
I r ❑ Not in Comm./Govt. 0 Not in Comm./Other
; _Y_ _-1 USDOT NO. ILCC NO. m
XI
Source of above z
'
. MCS 0 Yes 0 No 0 Unknown Out of Service 0 Yes ❑No 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
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
Blue Black
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO.
Arties/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE