HomeMy WebLinkAbout2025-00003685 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets II Ill H IIII 011101100
IHIlfll 00111
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0036.,8238
u, 1 U21 1 1 1 U1 2 U2 1 U, 1 1_12 1 U, 1 U2 1 1 11 U1 1 U2 1 *P 0 1 1 9*
INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and f or Tow Due To Crash YR 2025512025-00003685 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
S MCLEAN BLVD Elgin02:54
® ❑ RELATED ®Y 0 N 01 17 2025 ❑AM ❑YES ®NO U1 —<
_ _ PRIVATE mo !day/yr ®PM FLOW CONDITION m
FT!MI N E S W LILLIAN ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR IR SLOW 1 (n
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0
g 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 2 1 1 /
yr 13-UNDER CARRIAGE 10.I I: 2 FIRE 0
IE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14--TOTAL(ALL) DISTRACTED 0 El U2 2 m
M 2 OTHER
4 ❑Y ®SYSNEM IN❑UNK VEH. O AT CRASH D 0 99-UNKNOWN 9 76.70P 3 ,Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, ii_6 1, 4 COM VEH 0 El 1 O
H 1- HOFFMAN ESTATES IL 60192 0 1 0 FIRST CONTACT 6 T : --s •irYes.See Sidebar U1
Z EY26516 IL 2025 E
TELEPHONE
IL D 0 4T1 BE32K83U787461 State Farm ❑Y I l N U2 m
B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Drew.John. L. 2235700 SFP-13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 XI
g DRIVER ❑ PARKED 0 DRIVERLESS ❑ FED ❑PEDAL ❑EWES ❑r uv 0 NOV ❑DV
!1 9 yf 6 Fiat 500L 2017 00-NONE 0.. QI'-O DUE TO CRASH ❑ El 2 x
0mo 13-UNDER CARRIAGE 10 I f. 2 FIRE 0 ® U2 C
F 2 4 SYSTEM IN 0 ENGAGED 0 ®-OTHER 9,16-TOP 3 9 0 X
❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN `0istracton Value
POINT OF s i 4 COM VEH ❑ ® u1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6
H Inverness I L 60067 0 1 0 Q968059 I L 2025 FIRST CONTACT 6 �' ,Q.'Qs •,rvea See Sidecar 0 N
IL D 0 3C3CFFCR6HT694379 EG ASSURANCE ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 5009-540786 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 01 /17 /2025 02 54 ®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 C)
0 2 ❑ 28 03 / / 0 PM ❑Construction *
N 3 0 1!>I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
—a, ARREST NAME DREW.JOHN. L. 11-601 485339 / / ❑❑PM El Maintenance U2
oN ® 11 1 0 •CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility SLMT
El r 2 0 ARREST NAME AM
7 ( / pM 0 Unknown work zone type 25
U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 25
485-Quintana.Josue 601 02 /04/2025 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
R • 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
i- }_-__Y__--1 I.
— I Ig Iz i combination):or
Not To Scale I INDICATE NORTH C
` . _ 1 BY ARROW 2 Is used or designed to transport more than 15 C
_-_a_ g sp passengers including the driver
(example:shuttle or charter bus):or 0
-- II<a I ��"w` 3. Is designed to carry15 or fewer ig passengers and operated by a contract carrier 0
- } } } transporting employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
I I�''I C
;�I - } } } 4. Is used or designated to transport between 9 and 15 passengers,including the driver. N
J for direct compensation(example:large van used for specific purpose):or O
L i.____a____. l. i i. t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
u
placarding(example:placards will be displayed on the vehicle). ,Zmt
— — —
—1
CARRIER NAME Z
I I UMW?* I ADDRESS D
to
C)
I I CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate ❑ Intrastate
I I T I 1 I ❑ Not in Comm./Govt. ❑ Not in Comm./Other 00
-"-----"1 USDOT NO. ILCC NO. C
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'; 0 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
Gray Black
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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE