HomeMy WebLinkAbout2025-00016786 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111 01101100 lfl OOi 1� �l 111100
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00375563
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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 ❑$501-$1.500 ®ON SCENE 3
VEHICLE/PROPERTY ®OVER$1,500
El NOT ON SCENE(DESK REPORT)
El AMENDED ElB Injury and for Tow Due To Crash YR 202512025-00016786 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 71
174 RT20 EB Elgin07:08
® ❑ RELATED ®Y 0 N 03 15 2025 12— ❑YES ®NO U1 -<
PRIVATE mo /day/yr ®PM FLOW CONDITION IT1
_
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ FT l MI N E S W Kane HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD ® STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL ❑EDUCE ❑uuv ❑!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 0
0 4 !
Jeep(after 1911ngler 2020 00-NONE „_' Qi0 DUE TOCRASH ❑
13-UNDER CARRIAGE 10 : 2 FIRE 0 IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 3 <<T1
M 2 SYTM IN ENGAGE15-OTHER
4 ❑Y ®SNE DUNK VEH. 0 AT CRASHD 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2
V. POINT OF CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 8,
F. FIRST CONTACT 12 7__1 6 4_5 *Irves.See Sidebar U1 COM VEH 0 0 1
0
,_
Z WEST DUNDEE IL 60118 0 1 0 EE83243 IL 2024 T's
TELEPHONE
IL D 0 1 C4HJXDG8LW210363 State Farm ❑v Il N U2 ni
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 0879772-SFP-13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER XI
Refused ❑Y ® N 2 c
x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMy 0 KCV 0 DV
� !2 O 0 5 Scion FRS 2013 00-NONE ,t"i 12..-_, DUE TO CRASH ❑ C 2
o Yr 13-UNDERCARRIAGE 10;1 2 FIRE ❑ ® U2 C
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP 3 X
❑Y 10 N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istraellon Value 9 0
POINT OF 8 i 4 COM VEH D ® U1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6
FIRST CONTACT 6 7 -�I OS •IfYes.See Sidebar C
Belvidere IL 61008 0 1 0 FB85001 IL 2025 REAR
0 Si)
IL D 0 J F1 ZNAA18D1706886 State Farm ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 3514127-SFP-13 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ®Y U2 Z
N 1 ® 11 4 03,15 l2025 07 08 ®pm in a Work Zone? ❑N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 6
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
o"
2 ❑ 28 18 ) / 0 PM• ®Construction *
Z 3 ❑ xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 6
❑AM ❑Maintenance U2
o1 ® 11 4 ARREST NAME Holdcroft. David.C. 11-601 W1542-000164 ! ! El PM SLMT
o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility
0 AM
T 2 El ARREST NAME 03 r 15 l2025 07 30 ®PM El Unknown work zone type U1 45
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 D ❑AM Workers present? Y 45
1 Chafe. Ethan 401 , 0 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.
: 0
r ----r••--, ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
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�____r____; I _ 1. Hasaor more than pounds(example:truck ortruckrtrarler 1. Hasa weight rating10 000
INDICATE NORTH combination): -I
4.7..._._.,.
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
L ro��I _ (example:shuttle or charter bus):or X
I i o 3. Is designed to car 15 or fewer passengers and operated a contract carrier 0
L L----A---_-I ® _ } } . transporting employees in the courses of their employment(example:employee X
enger
L -----}----� .tom o Q_ - 1 } } 1 •transporter sed or des gnated to transport betweelly a van type vehicle or n 9 and passengers,15r including the driver,
C
-,, -- for direct compensation(example:large van used for specific purose):or
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
m
CARRIER NAME Z
ADDRESS T.
0\ C)
CITY/STATE/ZIP g
I I MOTOR CARR.ID 0 Interstate 0 Intrastate 50I I T I ❑ Not in Comm./Govt. ❑ Not in Comm./Other
I I
USDOT NO. ILCC NO. m
XI
Source of above z
. —I
Were HAZMAT placards on vehicle? 0 Yes 0 No =
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
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 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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE