HomeMy WebLinkAbout2025-00013627 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111 III 11 III1II IIIIII 0110001111111ll0IllIIl
DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X003741911
u, 1 U2 1 1 1 U116 u2 U, 1 1_12 u, 3 U2 1 6 U1 1 U2 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY El OVER 31,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 2025I 2025-00013627 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 71
HOPPS RD Elgin
® ❑ RELATED ❑Y ®N 03 02 2025 ®AM ❑YES ®NO U1 -<
PRIVATE mo /day/yr 11.49 ❑PM FLOW CONDITION M
010((1 /MI NOS W Umbdenstock Rd COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW Cl)
Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Ig:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUCE 0 NOV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 03 n
0 8 /
yr Honda Odyssey 2008 00-NONE _' Qi�OUETOCRASH ® ❑
�3-UNDER CARRIAGE 11t0 i Z FIRE 0 NI
•STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ ]$I U2 M
M 2 4 SYTM❑Y ®SNE❑UNK VEH. 0 AT CRASH 99-UUNKNOWN THER9 t6•TOP 3 *Distraction Value 5 ALGN •
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s_iL a �i,4 COM VEH ❑ 1� 1 0
F. FIRST CONTACT 1 Y _;__5 *IIYes.See Sidebar U1
Z SOUTH ELGIN IL 60177 0 1 0 JESS176 IL 2025 REAR
TELEPHONE
IL D 0 5FNRL38768B076255 Allstate ❑Y igiJ N U2 r 1 R
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 911859127 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ❑ N 2 0
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❑ DRIVER 0 PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 NMy 0 NCv 0 Dv
yr 12 _ 71
o 13-UNDER CARRIAGE 10 I c. 2 FIRE 0 ❑ U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP 3 0 ❑ SPDR n
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *OistraMIon Value U1 0 -
POINT OF 8-.;, 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT i —d:=5 C•IO e1sVEH •Sidebar❑ 0
C
CO
F` pEAR` co
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O
❑Y ❑N RDEF73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
BAC
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
RESPNDER❑YO❑N U1 =
(UNIT) (SEATI (DOB) (SEX) {SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(A.DDRESS)/(TELEPHONE) (EMS) (HOSPITAL) n
1 3 06 / F 2 3 0 1 0
I71
/ / #OCCS >
/ / UI 2 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 1 Elgin Parkway tree damage 03,02 /2025 11 49 ®❑pM AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
;, 2 ❑ 41 3 150 DEXTER CT ELGIN IL 60120 41 10
! / ❑PM, ❑Construction *
t
Z3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2
a ARREST NAME / / ❑PM '
o u 1 ❑ ❑CITATIONS ISSUED ❑PENDING UtilitySLMT
o N SECTION CITATION NO. ROAD CLEARANCE TIME ❑
t 2 El ARREST NAME 03/02 /2025 12 45 ®PM ❑Unknown work zone type U1 El AM 35
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y
❑
1543-Sturgeon. Kyle 700 272-Bajak / / ❑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 truckrtrailer -<
- } ' ' nt INDICATE NORTH combination):or -I
IBY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i_ } i I Not To Scale i - } (example:shuttle or charter bus):or 0
" ' jo [ 3. Is I- <-----I-•--; �� transporting mployeened to slin the course passengers5 or fewer thir emplod yment example:employeener X
} } }
transporter-usually a van type vehicle or passenger car):or �
L 4. Is used or designated to transport between 9 and 15 passengers,including rCjt
}-----}----; - } } } g po passen rs,includi the driver,
for direct compensation(example:large van used for specific purpose):or O
L l. i i ._ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires III
it 1 placarding(example:placards will be displayed on the vehicle). XI
—1
Qo,. CARRIER NAME Z
f
rt 1v/` ADDRESS 0I I 1 I „S." T.
0
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate El Intrastate
I . ❑ Not in Comm./Govt. 0 Not in Comm./Other
------- --1 - USDOT NO. ILCC NO. rn
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
v
TRAILER WIDTH(S) 0-96" 97-102" >102' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U_COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Brown
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Redmons/Impound Lot Garage . 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