HomeMy WebLinkAbout2025-00006457 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets HUI III 11 111111
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV
u, 9 U2 3 9 9 U, 2 U2 U199 1_12 U199 U2 9 6 U1 1 U2 *P 0119*
INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY 0 5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S 0$501-$1.500 ®ON SCENE 9
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
El AMENDED ElB Injury and/or Tow Due To Crash YR 202512025-00006457 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 -n
NATIONAL ST El 09:09
® ❑ RELATED ®Y 0 N 01 30 2025 ®AM ❑YES ®No u1 -<
_ _ g PRIVATE mo !day!yr ❑PM FLOW CONDITION m
FT!MI N E S W RAYMOND ST COUNTY PROPERTY :IY ® N DOORING Ely #OF MOTOR IR SLOW fA
❑ Kane 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
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
/ FOR DAMAGEDAREA(S) FROf4r TOWED U1 0
Unknown.O. Unknown Unknown 00-NONE „ 12 , DUE TOCRASH ❑ EN
NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 10 !�. 2 FIRE 0 IE C
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 m
SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3
9 9 ❑Y ❑N DUNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN =
s 4 COM VEH 0 ZgJ
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _,I[a !i._ 00
I- 0 9 FIRST CONTACT 99 7_; _5 *II Yes.See Sidebar U1
REAR
2 Z ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED
Unknown ❑Y ❑N U2 m
5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
co
Unknown 9 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
. Refused RESPONDER 0
5 0 DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0
yr 12 _ C1
o 13-UNDER CARRIAGE 1U I 2 FIRE ❑ ❑ 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 9 -
POINT OF s-.. 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 7A—d:-9 C•IO e1sVEH See •Sidebar❑ ❑ C
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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 99 =
BAC
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
RESP❑YD❑N NDER U1 =
(UNIT) (SEAT) (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 LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 43 4 City of Elgin black light pole 01 ,30 ,2025 09 09 ®❑PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 ,,
v t 2 150 DEXTER CT ELGIN IL 60120 99 99 ! ! 0 PM El Construction *
Z3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2
-a, ARREST NAME / / ID PM
o u ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT
30
r 2 0 ARREST NAME AM
7 ! r ❑❑PM 0 Unknown work zone type U1
cf n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y
2 3 ❑ - ❑AM Workers present? ❑
414-Lara. Saul 401 ! , ❑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
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
i- }____r____1 A combination):or
INDICATE NORTH p0
I II 1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
ryt9_ (example:shuttle or charter bus):or n
, 3. Is designed tocarry 15 or fewer passengers and operated a contract carrier O
I- I- --I-----; Not To Scale I - } } } transporting employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
L L.___a__ 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } • •
for direct compensation(example:large van used for specificpurpose):or [he driver,
(� � Pe ( P 9 Pe or O
L i — — — — — — L i i L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D
placarding(example:placards will be displayed on the vehicle). XI
—I
v - CARRIER NAME Z
ADDRESS 0g gc)I
CITY/STATE/ZIP
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
. GVWR/GCWR m
❑ <10,0oo 0 10,000-26,000 ❑ >26,000 z
Were HAZMAT placards on vehicle? 0 Yes 0 No =
If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. XI
XI
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 VIM 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U_COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
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_TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO.
DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE