HomeMy WebLinkAbout2025-00015239 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
I01101100 Ilfl
II 0010I111111
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003757469*
u, 1 U21 2 4 1 U1 2 U2 1 U, 1 1_12 1 U, 1 U2 1 1 10 U1 3 U2 1 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® 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 ®OVER$1,500
El NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and f or Tow Due To Crash YR 2025512025-000155239 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 m
® ❑ RELATED ❑Y ®N 03 09 2025 ❑AM ❑YES IX]PRIVATE NO U1
S MCLEAN BLVD Elgin mo /day/yr 01:06 ®PM FLOW CONDITION m
®2540/MI NOS w North Lillian St COUNTY PROPERTY El'COUNTY ® N DOORING ❑y #OF MOTOR 0 SLOW 2 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
18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
FOR DAMAGEDAREA(S) FROM TOWED U1 Q
NAME(LAST,FIRST,M) Charles.Albert. L. 0 9 / /1 9 y 3 Hyundai Tucson 2024 00-NONE Q. Q 17T DUE TO CRASH 0 13-UNDER CARRIAGE �) : 2 FIRE 0 IE <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O O DISTRACTED 0 0 U2 m
M 2 SY4 ❑Y ®SNE❑UNK VEH. 0 AT CRAS IN H 0 15-OTHER
99-UNKNOWN 9 16•TOP 3 `Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $_iL 6 4 COM VEH 0 j$J 1 0
I .
ELGIN I L 60123 0 1 FIRST CONTACT 12 7_; _5 *II Ves.See Sidebar U1
Z DF12869 IL 2026 REAR
TELEPHONE
IL 0 KM8JFCDE5RU341308 STATE FARM INS El ®N U2 at . m
IS EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 0248125SFP13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑y El 2 0
N DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED 0 PEDAL 0 EWES 0!My 0 i v 0 DV
Yr 7 Chevrolet Silverado 2007 00-NONE 1(' 12 Y1 DUE TO CRASH ❑ 2
0 13-UNDERCARRIAGE 1J FIRE El El U2C
c
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP-
❑Y Ni N ❑UNK VEH. AT CRASH 99-UNKNOWN O Oistraellon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s-iI 6 �., 4 COM VEH ❑ ® U1 CO
FIRST CONTACT 2 Y _�-`-�C.
ITYes.See SidebarC
ELGIN IL 60123 0 1 2510668B IL 2024 I 0
IL D 0 2GCEK13M871709875 STATE FARM INS ❑Y ®N RDEF M
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Same 2708440SFP13 BAC
$
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)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
W 06 /
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 03/09 /2025 01 06 ®AM in a Work Zone? ®N DIRP co
1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 1 n
T
2 ❑ 2 28 ( / ❑PM• ❑Construction *
o G
" 3 ❑ $I CITATIONS ISSUED 5 PENDING SECTION CITATION NO. EMS ARRIVED TIME
❑AM ❑Maintenance U2
o 1 ® 11 1 ARREST NAME Charles.Albert. L. 11-902 465-433 / / ❑PM SLMT
MI CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' ❑Utility
o N AM35
T 2 ❑ ARREST NAME Charles.Albert. L. 11-402-A 465-432 ( / 0 PM ❑Unknown work zone type U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 35
465-Doracio.Ariana 602 331-Ziegler 04 / 15/2025 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
I 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
' }---.r----; combination):or
INDICATE NORTH p0
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver n
_ } (example:shuttle or charter bus):or
X
- ------ -•-•; I - transportingdgemloyeeslin the course of 5 or fewer passengers planoyment(example:employee
a contract ner
gwa,,�,�� / iV I. r } transportr-usually a van type vehicle or passenger car): r CO
' . 4. Is used or designated to transport between 9 and 15 passengers,including cci'
}--- ----; - •} } } g po passen rs,includi the driver,
/ r for direct compensation(example:large van used for specific purpose):or O
L i.____a____. 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). IXI
II
Udrs _ _ D
CARRIER NAME Z
,i::_.• 0
.oe,--' — ADDRESS D
iI`I —0. w
r
CITY/STATElZIP
Not To Scale - MOTOR CARR.ID ❑ Interstate ❑ Intrastate O
I I T I I I ❑ Not in Comm./GaA. Not in Comm./Other
------- -'-: - 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. XI
XI
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?El❑ Yes II No 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 VIM 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' T
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 Blue
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE