HomeMy WebLinkAbout2025-00005463 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
I01101100 0 OlD 01000
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0037058.68*
u, 9 U21 1 1 1 U1 99 U2 1 U,99 1_12 1 U,99 U2 1 5 11 u1 99 U2 1 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ❑$501-51.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
0 AMENDED YR 202512025-00005463 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 -n
SHALES PKWY Elgin06:46
® ❑ RELATED ' V 0 N 01 25 2025 ❑AM YES ®NO U1 —<
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W CHAPARRAL CIR COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR IR SLOW 15 Co
❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD ❑ STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
yr 13-UNDER CARRIAGE 10 ! 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED U2 2 <
9 9 SYSTEM IN 9 ENGAGED 9 15-OTHER 9 16.TOP 3 ❑ _
❑Y ❑N ❑UNK VEH. AT CRASH ®-UNKNOWN `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8_iL s 1,.4 COM VEH 0 E! 1 0
0 9 0 FIRST CONTACT 99 7_i __$ *lIYes.See&debar U1
Z NIA Unknown REAR
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 3 D Unknown ❑Y ❑N U2 m
5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
co
Same Unknown 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF`Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
r RESPONDER 9 0
m
g DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 Nuy 0 NCv 0 Dv
/1 9 5 8 Ford Escape 2017 00-NONE ,�_"i t2'-_, DUE TO CRASH ❑ 2
0 13-UNDER CARRIAGE fir' 2 FIRE 0 ® u2 C
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F 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP 3 X
0 Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN *0istraellon Value 9
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 iII S �,_4 COM VEH ❑ ® Ut CO
FIRST CONTACT 6 Y__{_O ._5 •(ryes,See Sidebar
= ELGIN IL 60120 0 1 0 BXY749 IL 2025 REAR
IL D 0 1 FMCUOF71 HUA77062 State Farm ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 0180082-SFP-13 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
KNIT) (SEAT) (DOB) (SEX) {SAPT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 1 01 ,25 (2025 06 46 ®PM 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
Fsi 2 0 28 03
N 3 0 0 CITATIONS ISSUED 0 PENDING ( 1 0 PM• ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5
—a, ARREST NAME / / 0 PM '
oN ® 11 1 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT
t 2 El 35
NAMEAM
x- 7 ( / ❑❑PM 0 Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ 1529-Audi red.Jonathan 302 334-Fries 1 / D PM Workers present? ®N U2 35
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.
Shales?PIM/y/. A CMV is defined as any motor vehicle used to transport passengers or property and: D
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1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
i- i.-- ---- --' I I } INDICATE NORTH combination):or A
iN BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ } (example:shuttle or charter bus):or
II3. Is designed to carry15 or fewer` A D g passengers and operated by a contract carrier 0
} } } transporting employees In the course of their employment(example:employee P3
transporter-usually a van type vehicle or passenger car):or w
L L.___a____.l r } } } 4. Is used or designated to transport between9and15passengers,includingthedriver. N
for direct compensation(example:large van used for specific purpose):or o
L -a--- ? t i. i I 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
Chaparral Cir. m
placarding(example:placards will be displayed on the vehicle). ;p
—1
CARRIER NAME Z
ADDRESS 0
V)
CITY/STATE/ZIP n
O
_ MOTOR CARR.IDInterstate 0 Intrastate
Not To Scat!_I I 0
I I T I I ❑ Not in Comm./Govt. 0 Not in Comm./Other
0
Y
USDOT NO. ILCC NO. m
Source of above z
. 0 Yes 0 No ❑ Unknown 0
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
'LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 z
ri
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Blue
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 9 TOWED BY/TO.
SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE