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HomeMy WebLinkAbout2025-00004337 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets II III H II II IIIIII 011000111111110111011 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003700915 u, 1 U21 2 4 1 u, 3 U2 1 u, 1 1_12 1 U1 1 U2 1 3 15 u1 1 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ®5500 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 51,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ElB Injury and for Tow Due To Crash YR 202512025-00004337 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n COLLEGE GREEN DR Elgin04:53 ® ❑ RELATED ®Y 0 N 01 20 2025 12,— ❑YES ®NO U1 -< _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m FT!MI N E S W M U I RFI ELD CI R COUNTY PROPERTY ❑Y ® N DOORING ICIy #OF MOTOR El SLOW 15 co ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I ® 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 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0 FORDAMAGEDAREA(S) FRO Wilkinson. Michael. D. 0 9 / yr Nissan Altima 2022 00-NONE ©1 O i" , OUETOCRASH ❑ EN 13-UNDER CARRIAGE I , 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 0 10. m M 2 SYTM IN ENGAGED15-OTHER 4 ❑Y ®S NE❑UNK VEH. 0 AT CRASH 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, i�a 4 COM VEH ❑ Ea 1 0 F. ELGIN I L 60123 0 1 0 FIRST CONTACT 12 7 ; _5 *Ir yes.See Sidebar U1 Z LBM3207 PA 2025 REAR TELEPHONE IL D 0 1 N4BL4BV4NN315738 Aon Risk Insurance ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Hertz ASE-665-067247-474 1 rn `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER 25 (,0j p; DRIVER ❑ PARKED 0 DRIVERLESS ❑ FED ❑PEDAL ❑EWES ❑r uv 0 NCv ❑Dv CIRCLE NUMBER(S) U1 1 9 yr 3 Hyundai PALISADE 2022 00-NONE ,�_"j t2 "_, DUETO CRASH ❑ 2 0 13-UNDER CARRIAGE 1a 2 FIRE ❑ ® U2 C c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN O *Distraction Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 .i. B - 4 COM VEH D ® U1 CO FIRST CONTACT 5 Y ��iQS •byes,See Sidebar C ELGIN IL 60123 0 1 0 DE17221 IL 2025 REAR Si)0 IL D 0 KM8R5DHE6NU395538 American Family Insunrace ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Same 41025-46970-70 BAC $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER u1 = KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(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 4 01 ,20 /2025 04 53 ®pm in a Work Zone? ®N DIRP co 1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 2 ❑ 23 28 N 3 0 ❑CITATIONS ISSUED 0 PENDING + ) ❑PM• ❑Construction SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 3 —a, ARREST NAME ! 1 ID PM ' o u El 11 `1 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility SLMT 35 F 2 ❑ ARREST NAME AM 7 1 1 ❑❑PM El Unknown work zone type U1 n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ ❑AM Workers present? ❑Y 30 488-Ramos.Arely 702 334-Fries , / ❑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 asmotor vehicle used to transportand: r ----,5-••--, ; any passengers or property Z 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 X 3. Is L L.___A_. 1 <--_- -___� J transporting employened to es Inhecourse 5 or fewer o their eers mplod yment example:employeener X } } } transporter-usually a van type vehicle or passenger car):or 1:0 < <.__-a-_-_, , < <--_-a-___� , , , , 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or 0 L L___-a____.: 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). XI —D7 CARRIER NAME Z ADDRESS 0 CITY/STATE/ZIP MOTOR CARR.ID 0 Interstate ❑ Intrastate 0 ❑ Not in Comm./Govt. ❑ Not in Comm./Other O USDOT NO. ILCC NO. m XI Source of above z . If Yes,Name on placard 0 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 0 No 0 Unknown T. 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 co LOCAL USE ONLY TRAILER VIN 2 m 0 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 White White 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: 1 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE