HomeMy WebLinkAbout2025-00015138 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 4 Sheets 01111101111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑5501-51,500 ®ON SCENE 15
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) El Injury and/or Tow Due To Crash
El AMENDED
YR 2025I 2025-00015138 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 "1
® ❑ RELATED ®Y 0 N 03 08 2025 ❑AM ❑YES N NO U1 -<
BIG TIMBER RD Elgin11:01
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION ITl
FT!MI N E S W N STATE ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 2 co
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD DO
U2 --I
lgi AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0(Cy 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C)
0 9 !
yr 13-UNDER CARRIAGE I FIRE 0 N
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O O DISTRACTED 0 gi U2 0 rn
F 2 SYTM IN ENGAGEis-OTHER
8 ❑Y ®S NE DUNK VEH. 0 AT CRASHD 0 99-UNKNOWN 00 TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF D;i�6 �'.4 COM VEH 0 j$J 1 0
~ Batavia I L 60510 B 4 0 FIRST CONTACT 9 7 : __5 *IrYes.See Sidebar U1
Z DC16945 IL 2025 REAR
TELEPHONE
IL D KM8K62AB3NU827263 Unknown ❑Y ❑N U2 1-
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire Same Unknown 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Sherman ❑Y El 2 0
Eg DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED 0 PEDAL ❑EWES O!My 0 NCv 0 Dv
!2 0 0 3 General MotorSiQoq 2020' 00-NONE O1 ' Q1.O DUE TO CRASH gi ❑ 2 x
0 13-UNDER CARRIAGE FIRE 0 ® U2 C
c
M 2 5 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 1,6-TOP 3 X
❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN `OistracJDn Value 9 g
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-iI 6 i_i, 4 COM VEH ❑ N U1 CO
FIRST CONTACT 11 7�• _,__5 •If Yes.See Sidebar
~ 60110 0 1 0 3835487B IL 2025 I 0 So
M
IL D 1 GTU9BED4LZ150417 Statefarm ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 1722426sfp13 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (DM (SEX) {SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME),(A.DDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
2 3 10 /
:A
/ / UI 1 D
/ / 2 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 4 03,08 ,2025 11 01 ®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
v 2 ❑ 25 28 03,08 ,2025 11 01 ®PM ❑Construction *
R 3 ❑ gi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
z J ❑AM ❑Maintenance U2
a ® 11 4 ARREST NAME Buttacavoli. Karen. E. 11-601-Ax 1513000642 03,08/2025 11 06 N PM 0Utility SLMT
El CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME NAM
t 2 El ARREST NAME Buttacavoli. Karen. E. 3-707 1513000643 03,08 ,2025 11 55 N PM El Unknown work zone type U1 45
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 35
1513-Mann. Nathaniel 501 04 ,01 ,2025 01 30 ®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 -<
11
931
103
` ; combination):or —I
r i•----r r----, I - INDICATE NORTH p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- (example:shuttle or charter bus):or 0
L I I ' 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 }-----}----; ilss I. } 1} 4. Is used or designated to transport between 9 and 15 passengers,including the driver, to
EIR u.m w ; for direct compensation(example:large van used fors specific purose):or
i _ 5 Isanyvehcleusedtotransportan hazardous material(HAZMAT)thatrequires m
i i placarding(example:placards will bendisplayed on the vehicle).
M
CARRIER NAME Z
ADDRESS 0
w
CITY/STATE/ZIP n
MOTOR CARR.ID 0 Interstate El Intrastate
rvaTos Ia O
r ; ❑ Not in Comm./Govt. 0 Not in Comm./Other
----------1 - USDOT NO. ILCC NO. rn
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'; ❑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' m
TRAILER 1 0 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
White Gray
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
Arties/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® Arties/Impound.Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE