HomeMy WebLinkAbout2025-00004295 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 El$501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) El B Injury and f or Tow Due To Crash
0 AMENDED YR 202512025-00004295 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED coY 0 N 01 20 2025 ❑AM ❑YES ®NO U1 -<
WAVERLY DR Elgin01:46
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FTlMI N E S W JEFFERSON AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ Cook HIT&RUN ❑V ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 —I
lgi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ 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 0 C)
FOR DAMAGEDAREA(S) FRO T TOWED U1 Q
Hurst. Nicholas.J. 0 9 /
yr 13-UNDER CARRIAGE I FIRE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 2 0 DISTRACTED 0 U2 0al m
M 2 SY4 ❑Y ❑SNE®UNK VEH. 9 AT CRASH M IN D 9 99-UNKNOWN 9 76•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, i�6 ji COM VEH 0 0 1 0
F• Elgin IL 60120 0 1 FIRST CONTACT 11 7_: __5 *Il yes.See Sidebar U1
Z 9 DK75062 IL 2025 REAR
TELEPHONE
IL D 0 3N1AB8DV1 NY258613 Progressive ❑v Igl N U2 MI—
Ill
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR --1
Elgin Fire Same 966748454 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y El 2 0
x DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 Nov 0 NOV ❑Dv CIRCLE NUMBER(S) U1
'1 9 8 9 Chevrolet Trax 2015 00-NONE ,� 12 , DUE TO CRASH ❑ 2
0 13-UNDER CARRIAGE 161 2 FIRE ❑ ® U2 C
c
F 2 4 SYSTEM IN 9 ENGAGED 9 15-OTHER O16.70P 3 X
❑Y ❑N ®UNK VEH. AT CRASH 99-UNKNOWN *Oistractlon value 9 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF I 6 i!,_ COM VEH 0 ig ut CO
FIRST CONTACT 8 O7 _,__5 •(ryes,See Sidebar C
MADISON WI 53705 0 1 0 AUF5700 WI 2025 I 4 N
WI D 0 KL7CJPSB6FB223753 Progressive ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire Same 984054120 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 4 11 )01 /025 01 51 ®AM 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 C)
cii 2 0 2 28 11 r 01 l025 01 57 ®PM ❑Construction
F
R 3 0 El CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
z J ❑AM ❑Maintenance U2
a1 ® 11 4 ARREST NAME Hurst. Nicholas.J. 11-601-Ax W1525000499 11 r 01 r025 02 01 Igi PM SLMT
o N
0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility
AM
r 2 0 ARREST NAME 11 101 ,025 02 31 ®PM 0 Unknown work zone type U1 25
cf n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 25
1525-NavE.Oscar 201 275-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
Not To Scale ( 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
` ` --I -' I. INDICATE NORTH combination):or —I
/ BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i. I- A ' / - } (example:shuttle or charter bus):or OC
3. Is designed to carry15 or fewer passengers and operated a contract carrier O
i. } } } transporting employee in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
L }-----}----; / - I. } } •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
L L--_-a-.... / t l. I. 1 L 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
\ •D
placarding(example:placards will be displayed on the vehicle). XI
I- I- -:- '.. N.144.00 .I I* I• I• I-- --I- —I
, CARRIER NAME Z
/ \
`> ADDRESS D rn
\ \ CITY/STATE/ZIPg
. .: / 44040:
' 1 MOTOR CARR.ID 0 Interstate El Intrastate r
I I I / ❑ Not in Comm./Govt. ❑ Not in Comm./Other 00
--- --1 USDOT NO. ILCC NO. C
m
XI
Source of above z
. own tank)? 0 Yes 0 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 0 No 2
TRAILER VIN 1 m
to
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 Red
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