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HomeMy WebLinkAbout2025-00004518 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 111111111111 OUI 01100 011111 �� 11111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003700959 u, 1 U21 2 4 1 U1 2 U2 1 U1 1 U2 1 U1 99 U2 99 1 10 U1 11 U2 3 *P0119* INVESTIGATING AGENCY DAMAGE TO ANY El$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 2 VEHICLE/PROPERTY ®OVER 51,500 ®NOT ON SCENE(DESK REPORT) El AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00004518 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 '1 460 S MCLEAN BLVD El In 01:50 ® ❑ RELATED ®Y 0 N 01 21 2025 ❑AM ❑YES ®NO U1 -< _ g PRIVATE mo !day!yr ®PM FLOW CONDITION MCOUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 6 (n ❑ FT/MI NESW Kane HIT&RUN ❑Y ® N WITH VEHICLESOT, INVLD ❑ STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUCE 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 n FOR DAMAGEDAREA(S) FROPtf TOWED U1 Q NAME(LAST,FIRST,M) mo /1 9 9 9 General Motort500 2015 00-NONE 13-UNDER CARRIAGE ©,I, 12 , DUE TO CRASH ❑ !�. 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 4 rn M 2 SYTM IN ENGAGE15-OTHER 4 ❑Y ®SNE❑UNK VEH. 0 ATCRASHD 0 99-UNKNOWN 916•TOP 3 `Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF & it S �i COM VEH 0 0 1 H F. Burbank IL 60459 0 1 EP89973 IL FIRST CONTACT 11 7_: __s Yes.See Sidebar Ut 0 Z REAR E TELEPHONE IL D 0 1 GTW7FCF7F1261900 Western National ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Prucha.Greg CPP1346182 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 1473 N DRIVER 0 PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 NMV 0 NCv 0 Dv CIRCLE NUMBER(S) U1 !1 9 9 8 Ford Super 2020' 00-NONE ,t_' t2.._, DUE TO CRASH ❑ 21 98 xi o Yr 13-UNDER CARRIAGE 10) 2 FIRE ❑ ® U2 C c M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER O9 16.70P 3 X ❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistrac on Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF si S l!-4 COM VEH ❑ ® U1 CO F,,, FIRST CONTACT 9 7 -5 •If Yes.See Sidebar C E LG I N I L 60120 0 1 191118 H I L REAR Si)0 Z IL C 1 F65F5KNOLOA10481 Acord ❑Y J N RDEF 7) EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = 99 9 Amazon Logistic RAC9438595 SAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)1(TELEPHONE) (EMS) (HOSPITAL) U2 996 r m ##occs y / ,, U1 1 D 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 4 01 ,21 l2025 02 15 ®AM in a Work Zone? ®N DIRP co 1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C) 2 ❑ 18 18 N 3 0 0 CITATIONS ISSUED 0 PENDING • + ! ❑PM• ❑Construction SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 7 —a ARREST NAME ! ! El ' S' N ® 11 `1 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility SLMT , r 2ARRESTNAMEAM 7 ❑PM ❑Unknown work zone type U1 El 1 / ❑ n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ - ❑AM Workers present? ❑Y 30 547 Homeier.William r 1 ❑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-- --; } } } i- -, , ; ; , 1, ( INDICATE NORTH combination):or —I p1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } ' , } (example:shuttle or charter bus):or X 3. Is . L.-_------ 1 ..._- - J transporting edmployeeslIn5 hecourseeo theire rsmployment exam pal e:employeener 73} } } transporter-usually a van type vehicle or passenger car):or c0 < <.__-a-_-_- , l• < <--_-a-___� . , , , 4. Is used ordesi nated to trans rt between 9 and 15 passengers,including C} } for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or 0 L L---------_.: L L L ...._-..:__ ; t 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 —1::.7 CARRIER NAME Z ADDRESS 0 T. , n CITY/STATE/ZIP MOTOR CARR.ID 0 Interstate 0 Intrastate 0 ❑ Not in Comm./Govt. ❑ Not in Comm./Other 0 USDOT NO. ILCC NO. m XI Source of above z . 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' -n TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 0 o u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w White u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ElNOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO: _ SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE