HomeMy WebLinkAbout2025-00015855 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100 HIH 1101100
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0037.5G286
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY El OVER$1,500
El NOT ON SCENE(DESK REPORT)
El AMENDED ElB Injury and f or Tow Due To Crash YR 2025I 2025-000158555 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 7 m
ELY ST Elgin09:22
® ❑ RELATED ®Y 0 N 03 11 2025 ❑AM ❑YES El NO U1 -<
_ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION m
FT l MI N E S W STANDISH ST COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR IR SLOW 2 fA
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0
Q83 DRIVER O PARKED El DRIVERLESS 0 PED p PEDAL 0 EWES 0 NUV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 1 0
0 5 FOR DAMAGEDAREA(S) FROPtf TOWED U1 0NAME(LAST,FIRST,M) Macrogers.Aaron mo Unknown Unknown 2020 00-NONE
DUE TOCRASH ❑ EN
O/ / yr 0. 12
13-UNDER CARRIAGE a I I! 2- FIRE 0 IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ga U2 1 r<rl
M 2 SY4 ❑Y ®SNE DUNK VEH. 0 AT CRASH M IN D 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, �--it S �i_; 4 COM VEH El 0 1 0
F. FIRST CONTACT 11 7_; __-S *IIYes.See Sidebar U1
Z West Salem WI 54669 0 1 0 38180Z WI 2025 REAR
TELEPHONE
WI Other 7 Cornerstone Insurance ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
99 9 1 M OTI M E LLC 986722903 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF`Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
98 0
p DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMy 0 Ncv 0 DV CIRCLE NUMBER(S) U1
yr _ 13-UNDER CARRIAGE 10 I 12 -2 FIRE 0 ® U2 C
Ti SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
`a SYSTEM IN 0 ENGAGED 0 15-OTHER 016.70P 3 0 ® SPDR n
❑Y ®N DUNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value 0 -
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF O I A '; 4 COM VEH ❑ El U1 CO
FIRST CONTACT 9 1, i:s •If Yes.See Sidebar C
71847B-B IL 2025 REAR0 Si)
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
1 FTZX18W2WNA25477 State Farm 0 Y ®N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 MORA.SAUL 0806319SFP BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (008) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
0
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
u 1 ® 18 1 03,11 l2025 09 22 ®AM in a Work Zone? ®N DIRP co
I I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 2
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
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2 20 99 1 , ❑PM ❑Construction *
1
Z3 0 1!>I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5
o1 ® 11 1 ARREST NAME Macrogers.Aaron 11-709-A 1528-000235 / ! El PM SLMT
o N 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
0 AM
t 2 El ARREST NAME 03 r 1 1 12025 09 00 ®PM El Unknown work zone type U1 25
2 2 3 El OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 25
1528-Rivera. Kevin 701 04 ,28,2025 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.
A CMV is defined asmotor vehicle used to transportand:
r ----,5-•---, ; any passengers or property
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1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
} i.-- -i-- --; } } } r -, , ; ; , ; ( 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 1:0
< <.__-a-_-_, , < <--_-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 ...._-�____� l. 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.
-D7
CARRIER NAME 1 MOTI M E LLC Z
ADDRESS 330 LARK LN 0
CITY/STATE/ZIP West Salem 1 WI 154669 g
MOTOR CARR.ID El Interstate ❑ Intrastate
0
❑ Not in Comm./Gout. ❑ Not in Comm./Other O
: -Y- --4 ; : : Y- ; ; ; ; 74057 USDOT NO. 36 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-; ❑Yes ®No 2
TRAILER VIN 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ M Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 53 ft. 2 ft. Z
White
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: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE 2 LOAD TYPE 5