HomeMy WebLinkAbout2025-00018747 (2) ILLINOIS TRAFFIC CRASH REPORT Sheet 3 of 4 Sheets HUI III 11 111111
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 10
VEHICLE/PROPERTY ®OVER 91,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
0 AMENDED YR 2025I 2025-00018747 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME
181 RT20 EB El08:50 SECONDARY CRASH 1 �1
® ❑ RELATED ❑Y ®N 03 25 2025 ®AM ❑YES ®NO U1 -<
_ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 2 fA
❑ FT!MI N E S W Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
QT3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
FOR DAMAGEDAREA(S) FRONT TOWED U1 Q
NAME(LAST,FIRST,M) y- mo
/20 0 1 Chevrolet Malibu 2019 00-NONE 11 O DUE TO CRASH ❑ EN
13-UNDER CARRIAGE 10:r 2 ' 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
M 2 SY 15-OTHER
4 ❑Y ®SNE❑UNK VEH. O AT CRASH M IN D O 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2
r POINT OF CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 8 iII a ii,4 COM VEH 0 Ea 1 00
F. FIRST CONTACT 6 7_; ,LQ_-5 *Irves.See Sidebar Ut
Z SOUTH ELGIN IL 60177 0 1 0 BT33772 IL 2025
TELEPHONE
IL D 0 1 G 1 ZB5ST5KF187749 State Farm ❑Y ®N U2 M
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 1 99 9 Same 2800146sfp-13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 2 0
p; DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑NMv 0 KDV ❑DV
1 9 5 2 Chevrolet Colorado Pickup 2018 00-NONE 11_"i t2..-_1 DUETO CRASH ❑ !g 2
or 13-UNDERCARRIAGE 10;1 2 FIRE 0 El U2 C
c
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP
3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraglon Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 I S .!. 4 COM VEH ❑ ® Ut CO
FIRST CONTACT 6 7A-�'r,_5 •If Yes.See Sidebar
REAR C
ELGIN N
IL D 0 1 GCGTDEN5J1226600 State Farm ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Elgin Fire 1 99 9 Same 1936676-sfp-13 BAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND O N U1 =
KNIT) (SEAT) (DOS) (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 1 03,25 ,2025 08 50 ®❑pM in a Work Zone? ❑N DIRP co
PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: U1 3 n
isi T 2 ❑ 11 1
❑AM
1 N 3 ❑ 0 CITATIONS ISSUED 0 PENDING + ❑PM ❑Construction >F
SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM ®Maintenance U2
-a, ARREST NAME / / ❑PM '
o N ® 11 1 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT
55
r 2AM
7 ❑PM ❑Unknown work zone type U1
El NAME 1 / ❑
n 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ®Y 55
324-Phillos.James 401 05 , 13,2025 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.
0 A CMV is defined as for vehxae used to tra and:
r ----,5-••--, ; any mo nsport passengers or property
Z
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -
} }-- -;-- --; } } } r -, , ; ; , 1, ( combination):or —I
INDICATE NORTH X1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ' J. , } (example:shuttle or charter bus):or
X
3. Is
. L.___A_. 1 i. <--_... . J transporting edmployeeslin5 hecourseeo theire rsmployment exam pal
e:employeener 73} } }
• � . transporter-usually a van type vehicle or passenger car):or co
< <.__-a-_-_, , < .---_-a-___� , J. , , 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____.I L L L ...._-..i._ 1 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
i.
ADDRESS 0
th
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other O
USDOT NO. ILCC NO. m
73
Source of above z
) ❑ Side of Truck [0 Papers 0Driver ❑ Log Book m
Z
GVWR/GCWR 1
El <10,000 0 10,000-26,000 0 >26,000 z
Were HAZMAT placards on vehicle? 0 Yes 0 No =
If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. P3
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? 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
73
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 3 COLOR U 4 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
White Red
u 3 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 4 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE