HomeMy WebLinkAbout2025-00005028 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Df 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003701 52
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INVESTIGATING AGENCY DAMAGE TO ANY El 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 14
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
El AMENDED ElB Injury and for Tow Due To Crash YR 202512025-00005028 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 —n
LAWRENCE AVE El In08:51
® ❑ RELATED ®Y 0 N 01 23 2025 ❑AM ❑YES ®NO U1 -<
g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FTlMI N E S W N WESTON AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD DO
STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Qg3 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 C)
T TOWED U1 Q
NAME(LAST,FIRST,M) pmo yr
Thom son, Madison.G. Honda Civic 2002 00-NONE ,, • 12 , DUE TOCRASH ❑ ENE
13-UNDER CARRIAGE 101 2 FIRE 0IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 23 U2 0 m
F 2 SYTM IN ENGAGE15-OTHER
4 ❑Y ®SNE El LINK VEH. 0 AT CRASHD 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2
T. CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ iI a �i COM VEH ❑ Ea 1 0
F• Elgin I L 60124 0 1 0 FIRST CONTACT 1 7 . -_5 *Irves.See Sidebar U1
Z 9 DU90228 IL 2025 Ismi
TELEPHONE
IL D 0 1 HGES26722L068898 Progressive ❑Y IlN U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
99 9 Thompson. Peter,J. 990098957 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE.ZIP PHONE NUMBER
RESPONDER
2 eu
N DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEOAL 0 EWES ❑row 0 e v 0 DV
1 9 9 7 Ford Explorer 2023 00-NONE ,i_"j t2..-_, DUE TO CRASH ❑ ! l 6 x7
oday Yr 13-UNDER CARRIAGE 10'I c., 2 FIRE ❑ ® U2 C
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X
❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraglon Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 0'i i.;., 4 COM VEH ❑ ® U1 CO
FIRST CONTACT 8 7 _, _5 •Iryes.See Sidebar C
ELGIN IL 60120 0 1 0 MP 22754 IL 2025 0 Si)
M
IL D 0 1 FM5K8AC9PGB13403 Charter Oak Fire Insuranc ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 City of Elgin 8109160P901 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJ) (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(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 01 ,23 i2025 09 16 ®PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 6
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
0 2 ❑ 28 03 + ) ❑PM ❑Construction *
R 3 ❑ $I CITATIONS ISSUED El PENDING SECTION CITATION NO. EMS ARRIVED TIME 6
❑AM ❑Maintenance U2
o ® 11 4 ARREST NAME Thompson, Madison,G. 11-601 W1542-000087 r r El PM SLMT
o N 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility
AM
t 2 ❑ ARREST NAME 01 123 r2025 08 51 ®PM El Unknown work zone type U1 3O
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 D 1542-Chace, Ethan 601 - 1 r ❑❑PM Workers present? ®N U2 30
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
1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
` ` -' -' r INDICATE NORTH combination):or .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
(example:shuttle or charter bus):or n
r 3. Is designed tocarry 15 or fewer passengers and operated a contract carrier O
` A i Not To Scale I - } } } transportinggemployees In the course of their employment
p ypbyment(example:employee
y a van type
C
< ...l. 1 I4. Is�sedordrter- �llnatedtotransehrtbetweeicle or n9 and r15r) ssen rs,including[hedriver,
} } for direct compensation(examp:large van used for specific purpose):or
itorin
t l. I I 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). ;p
_ _ CARRIER NAME Z
ADDRESS
D
n
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
I r ❑ Not in Comm./Govt. 0 Not in Comm./Other
i "Y""1 USDOT NO. ILCC NO. m
XI
Source of above z
. If Yes,Name on placard O
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
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' -n
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Black 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: 0 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE