HomeMy WebLinkAbout2025-00004691 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
101101100 0 11101 110
DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X003702281
u, 1 U2 1 1 3 U1 1 U2 U, 1 U2 U, 1 U2 1 6 U1 1 U2 *P 0119*
INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY El OVER$1,500 El NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and f or Tow Due To Crash YR 2025512025-00004691 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
413 LAWRENCE AVE El In 10:08
® ❑ RELATED ❑Y ®N 01 22 2025 ®AM ❑YES ®NO U1 -<
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR IR SLOW Cl)
❑ FT/MI N E S W Kane HIT ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
&RUN
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEOAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
0 4 /
yr 13-UNDER CARRIAGE IE
10l !!. 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ ]$I U2 m
M 2 SY is-OTHER
4 ®Y ❑SNE❑UNK VEH. 4 AT CRASIN H 0 99-UNKNOWN 9 t6•TOP 3 *Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 7 iI a �i 4 COM VEH ❑ Ea 5 0
F• Elgin I L 60123 0 1 0 FIRST CONTACT 1 7_;- -_5 *II Yes.See Sidebar U1
Z 9 65873EL IL 2025
TELEPHONE
IL D Tesla El ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
co
1 99 9 Same TLA-IL-A-9999Q4YD 3 m
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 2 0
❑ DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NI ❑NCv 0 CIRCLE NUMBER(S) U1
Dv
yr 12 _ C1
o 13-UNDER CARRIAGE 10 I 2 FIRE 0 0 U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 ❑ 0 SPDR 0
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value U1 0 -
POINT OF s-.;, 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 7A—d:-6 COM•I sVEH See •Sidebar❑ 0
C
CO
F` ---- co
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O
❑Y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
BAC
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
RESP❑YD❑N NDER U1 =
(UNIT) tSEATI (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0
/ / U2 r
m
Pj
/ / U1 1 D
0
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 36 1 01 !22 /2025 10 20 ®❑pm in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 ❑ 11 18
t / / ❑PM, ❑Construction *
Z3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2
-a, ARREST NAME / / ID PM '
o u 1 ❑ ❑CITATIONS ISSUED ❑PENDING UtilitySLMT
SECTION CITATION NO. ROAD CLEARANCE TIME
o N ❑
AM U1 25
t 2 El ARREST NAME 01/22 /2025 10 20 M PM ❑Unknown work zone type
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y
2 3 CI ❑AM Workers present? 0
435-Mahan. David 607 272-Bajak / / ❑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____; I _ 1. Hassaor more than pound (example:truckortrucktrailer 1. a weight rating10 000 5 � -<
INDICATE NORTH combination): p0
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- (example:shuttle or charter bus):or
X
I A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
} } } transporting employees In the course of their employment(example:employee X
I0 transporter-usually a van type vehicle or passenger car):or C
L L.__-a__ I } } } 4. Is used or designated to between 9 andpassengers,indudirg[hedrNer,
for direct compensation(example:large van used fors specific purose):or
L--_-a-___-I - l. i i i L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). XI
D
CARRIER NAME Z
Z
ADDRESS '0
D
Not To Scale I I n
CITY/STATE/ZIP g
..aoemra.. l - i. i. i. i. MOTOR CARR.ID ❑ Interstate ❑ Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
‘I. - --1 USDOT NO. ILCC NO. m
XI
Source of above z
. ❑ Yes II No ❑ Unknown A
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_COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Black
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO.
_Other/Unknown . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U_DUE ETOO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO:
DUE T VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE