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HomeMy WebLinkAbout2025-00014837 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 6 Sheets 01111101111 101101100 011011 1110 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0037489ar u, 1 U21 1 1 2 U116 U2 1 U, 1 1_12 1 U, 1 U2 1 1 12 U1 18 u2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El 5500 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 11 VEHICLE/PROPERTY ❑OVER 51,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00014837 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 6 �I ® ❑ RELATED PRIVATE ❑Y ®N 03 07 2025 ❑AM ID YES El NO U1 -< RT20 WB Elgin mo /day/yr 03.18 ®PM FLOW CONDITION M ^ COUNTY PROPERTY 0 Y ® N DOORING ❑y #OF MOTOR 0 SLOW 4 Cl) 12gal ® ©/MI N E S Grace St WITH VEHICLES INVLD 0 STOPPED U2 --I 0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑V ® N PEDALCYCLIST IZI N ® FREE FLOW # LNS 0 Ig:DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑NW ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0 FOR DAMAGED AREA(S) FRONT TOWED U1 Q Podolak. Robert.A. 0 7 / yr 13-UNDER CARRIAGE 10 IE 1 ! 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTEDTHER 0 0 U2 2 rr1 M 2 4 SYTM❑Y ®SNE❑UNK VEH. 0 AT CRASH 0 15-99-UUNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2 r COM VEH 0 Ea 1 C) CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ it 6 V4 ~ ELGIN I L 60123 0 1 0 FIRST CONTACT 7 ti __5 *II Yes.see Sidebar U1 0 Z 3579809B IL 2025 REAR TELEPHONE IL D 0 3FT1W8E92NRB07317 Country IlN Financial ❑Y U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same PO10313794 2 r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER X* Refused 0 Y ® N 2 c Eg DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑row /1 9 6 1 International C3 1 Mfg 2016 00-NONE 1("j 12..- 1 DUE TO CRASH ❑ ® 33 �7 o _ 13-UNDER CARRIAGE 10'i :., 2 FIRE 0 ® U2 C M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 1,6-TOP 3 X ❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value 9 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-iI�1:--4 COM VEH ❑ ® U1 CO FIRST CONTACT OO Y A _, .5 •If Yes.See Sidebar 11... C ELGIN IL 60120 0 1 0 83191SB IL 2019 M IL 7 4DRBUC8N2GB166075 Alliant Insurance ❑Y ®N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 8 x U46 School District P4-1001458-2425-01 BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (DOBi (SEX) (SAFT) (AIR) (INJ) 1(EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 2 7 1 2 / U2 10 Z EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y N 1 ® 11 1 31 /12 /25 03 18 ®AM in a Work Zone? ®N DIRP co 1 r PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 7 C) T o" 2 ❑ 2 99 / / 0 PM• 0 Construction 'A 13 ❑ El CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 ❑AM 0 Maintenance U2 o1 ® 11 1 ARREST NAME Podolak. Robert.A. 11-905 474000620 / / El PM SLMT o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility t 2 ❑ ARREST NAME AM T / / pM 0 Unknown work zone type 55 U1 2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 55 474-Jacobs.Tyler 401 4/ / 12 /25 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. A CMV is defined asmotor vehicle used to transportand: r ----,5-••--, ; any passengers or property Z 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -< } i.-- -i-- --; } } } r -, , ; ; , 1, ( INDICATE NORTH combination):or —I p1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } ' i 1 , } (example:shuttle or charter bus):or X 3. Is L L.___A_. 1 <--_- -___� J transporting employened to es Inhecourse 5 or fewer o their eers mplod yment example:employeener X } } } transporter-usually a van type vehicle or passenger car):or CO < <.__-a-_-_, , 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 0 L L___-a____.: L L L ...._-..:_____� t i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires placarding(example:placards will be displayed on the vehicle). XI --I CARRIER NAME Z ADDRESS 0 T. CITY/STATE/ZIP MOTOR CARR.ID 0 Interstate ❑ Intrastate 0 ❑ Not in Comm./Govt. ❑ Not in Comm./Other O USDOT NO. ILCC NO. m 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 to 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 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Blue Yellow 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: 0 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE