HomeMy WebLinkAbout2025-00005790 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and for Tow Due To Crash YR 2025I 2025-00005790 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 5 -n
PAMELA DR Elgin03:05
® ❑ RELATED ❑Y ®N 01 27 2025 DAM ❑YES ®NO U1
g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT l MI N E S W KATHLEEN DR COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR NI SLOW 15 Cn
❑ Cook 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 I] PARKED I]DRIVERLESS 0 PED CI PEDAL 0 EWES 0 NW 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 n
FOR DAMAGEDAREA(S) FRONT TOWED U1 O
NAME(LAST,FIRST,M)
H U LTZ. PAU L.V. mo /1 9 5 5 Navistar 7400 2019 00-NONE „ 12 , DUE TO CRASH ❑ EN
13-UNDER CARRIAGE fal !�. 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 0 m
M 2 4 ❑Y ®SNEM❑ 15-OTHER
UNK VEH. 0 AT CRASHIND 0 99-UNKNOWN 9 16•TOP 3 ,Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ i� B �r.4 COM VEH 0 0 1 n
I— FIRST CONTACT 5 7 :, :t-OS •IIYes.See Sidebar U1 0
... ELGIN IL 60123 0 1 0 105742SB IL 2025 REAR
TELEPHONE
IL B 7 4DRBUC8N9KB361003 Alliant Insurance Company ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 SCHOOL DISTRICT U-46 P41001458242501 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
28
0 DRIVER X. PARKED 0 DRIVERLESS 0 FED ❑PEDAL 0 EWES 0 NMV 0 KCv 0 DV
!1 9 9 8 Ford Explorer 2015 00-NONE 1("j 12..-_, DUETO CRASH ❑ ! l 6 �7
o 13-UNDER CARRIAGE ,a 1 2 FIRE ❑ ® U2 C
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `0istraellon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF �SiI S i.�, COM VEH D ® Ut CO
FIRST CONTACT 7 0_t—�•�5 •If Yes.See Sidebar C
E LG I N IL 60120 0 1 MP22181 IL 2024 REAR N
IL D 0 1 FM5K8ARXFGB12960 Alliant Insurance Service ❑Y ®N RDEF M
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 City of Elgin 8109160P901 BAC 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)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
0 O
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 18 1 01 ,27 /2025 03 05 ®pm in a Work Zone? ®N DIRP co
I I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
2 ❑ 04 99
N 3 ❑ 0 CITATIONS ISSUED 0 PENDING + / ❑PM• ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
-a, ARREST NAME ! / ID PM
o N ® 11 1 •
0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility
SLMT
r 2 El25
ARREST NAME AM
7 1 1 ❑❑PM ❑Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ - ❑AM Workers present? ❑Y 25
1515-BellEck.Stacy 602 , / ❑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
A ADDITIONAL UNITS FORMS.
r ----r••--, I A CMV is defined as any motor vehicle used to transport passengers or property and: Z
N 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
: 0
i- ------I-----; Not To Scale - ( comb nation)or
INDICATE NORTH �1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver n
i ReoIIIIJrl�ltri i _ (example:shuttle or charter bus):or X
L 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
transporter-usually a van type vehicle or passenger car):or w
L u1ThAtti 4. Is used or designated to transport between 9 and 15 passengers,including N
-- - •} } } g po passen rs,includi the driver,
7 for direct compensation(example:large van used for specific purpose):or
I I grlri.
L L____a_ y L L 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
1 - In - placarding(example:placards will be displayed on the vehicle). m
U, 2 XI
CARRIER NAME Z
•r i _ ADDRESS D
,.Q 0
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
-"------"1 - USDOT NO. ILCC NO. rn
XI
Source of above 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?
❑ Yes II No ElUnknown 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
to
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. w
Yellow Black
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