HomeMy WebLinkAbout2025-00008783 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 4 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003727523
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INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 2025I 2025-00008783 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m451 VILLA ST El In01:18
® ❑ RELATED ❑Y ®N 02 10 2025 ®AM ❑YES ®NO U1 -<
g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
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COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15 u)
❑ FT/MI NESW Cook HIT&RUN ®Y ❑ N WITH VEHICLES INVLD DO
U2 --I
O AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv p!Cy 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
FOR DAMAGEDAREA(S) FROPtf TOWED U1 Q
NAME(LAST,FIRST,M) mo
/1 9 7 8 Dodge Journey 2015 00-NONE „ 12 , DUE TO CRASH ® ❑
13-UNDER CARRIAGE ) FIRE ❑ tz
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 1U O DISTRACTED ❑ 0 U2 2 rn
F 9 SY 15-OTHER
9 ❑Y ®SNE❑UNK VEH. O AT CRASM IN H O 99-UNKNOWN 9 16•TOP 3 ,Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s 6 j- COM VEH ❑ Ea 1 0
~ ELGIN I L 60120 0 9 0 FIRST CONTACT 2 7_; __5 *Il Yes.See Sidebar Ut
Z ER14214 IL 2025 E
TELEPHONE
IL D 0 3C4PDCABXFT671028 The General ®Y ❑N U2 Si . m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 1CIL6519252 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 99 0
0 DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMV 0 Ncv 0 DV
yr Ford Explorer 2019 00-NONE 11_j 12 -_, DUE TO CRASH ❑ (� 6
o 13-UNDER CARRIAGE 'IFIRE ❑ ® U2
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10- f O DISTRACTED ❑ ® SPDR n
SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 0
a ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraglon Value
POINT OF s 4 Ut
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6 l.'._ C.OM VEH D ® C
FIRST CONTACT 2 7 _,__5 •If Yes.See Sidebar
H M220868 IL 2024 I 0 Si)
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
0 1 FM5K8AR5KGB44063 Alliant Insurance ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
City of Elgin 8109160P901 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
1 3 01 / F 2 3 0 1
m
/ / #OCCS D
71
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2Z
N 1 ® 18 1 co
02,10 /2025 01 18 ®p PM AM in a Work Zone? ®N DIRP D
1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 3 n
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o"
2 0 2 19 ( r 0 PM ❑Construction X
4
Z 3 0 CITATIONS ISSUED 3 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2
-, ® 11 1 ARREST NAME Stevenson. Dicsett.C. 11-601 751887 , ! El PM SLMT
MI CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
o N AM 30
t 2 0 ARREST NAME Stevenson. Dicsett.C. 11-402-A 751886 , r O PM 0 Unknown work zone type U1
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1515-BellEck.Stacy 401 03 , 17,2025 09 00 ❑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 -<
` ` ''- ' + r INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
N _ (example:shuttle or charter bus):or C
Not To Scale 1 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
1.
4. Is used or designated to transport between 9 and 15 passengers,including C
} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or 0
L i t i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). XI
Z
\\\\ CARRIER NAME Z
_ __ ADDRESS O
w
CITY/STATE/ZIP 00
- i. MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
; _Y_ __1 - USDOT NO. ILCC NO. m
XI
Source of above z
. 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'; 0 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' -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: 1 TOWED BY/TO.
_Adieu/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE