HomeMy WebLinkAbout2025-00019071 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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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 ®5501-$1.500 ®ON SCENE 11
VEHICLE/PROPERTY ❑OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00019071 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
RT20 WB Elgin 01:11
® ❑ RELATED ®Y 0 N 03 26 2025 ❑— ❑YES ®NO U1
g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W N RANDALL RD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (/)❑ 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
g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 5 n
FRON r TOWED U1 Q
NAME(LAST,FIRST,M) Schwarz. Linda. M. mo yr Cadillac SRX 2016 00-NONE 11 O I_1 OUE iO CRASH El ENE
13-UNDER CARRIAGE 1a : 2 FIRE 0 NI
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL)THERDISTRACTED ® 0 U2 5 M
F 2 4 SYTM❑Y ®SNE❑UNK VEH. 0 AT CRASH 0 15-99-UNKNOWN 9 16•TOP 3 *Distraction Value 5 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR
F. POINT OF $ iI 6 4 COM VEH 0 El 5 0
FIRST CONTACT 12 7 , _5 *IIYes.See Sidebar Ut
Z St Charles IL 60174 0 1 0 BE37660 IL 2026 Is
TELEPHONE
IL D 0 3GYFNCE34GS543512 State Farm ❑v ®N U2 M
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
1 99 9 Same 1328757sfp13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 2 c
g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 iiuv 0
1 9 8 6 BMW X4 2018 Do-NONE 1.11 12..- 1 DUE TO CRASH 0 2 x
0 13-UNDER CARRIAGE 10 1 2 FIRE ❑ ® U2 C
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F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 6
FIRST CONTACT 6 7I- 4 COM VEH ❑ ® U1 to
•(ryes,See Sidebar C
— Wayne IL 60174 0 1 0 DJ28988 IL 2025 PEAR 0 Si)
IL D 0 SUXXW3C53JOT81039 American Family Insurance ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
1 99 9 Werner. Matthew.J. 410722803768 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPT(i) PASSENGERS&WITNESS ONLY (NAME)l(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
1 3 02 / F 2 3 0 1 0
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/ / #OCCS D
/ / UI 2 m
/ / 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
u 1 ® 11 1 3/ 1 6/ ,025 01 11 ®PM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 ,,
0 2 0 28 41 , , ❑PM ❑Construction *
1 •
Z3 0 lyg CITATIONS ISSUED El PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 3
a1 ® 11 1 ARREST NAME Schwarz. Linda. M. 11-601-Ax 1552000020 , / El PM SLMT
`no N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility
El AM
r 2 El ARREST NAME 3/ r 6/ 1024 01 16 ®PM 0 Unknown work zone type U1 25
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 25
1552-Thompson.Ahmad Rashad 901 397-Jones 3/ , 6/ ,025 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 truck trailer -<
} 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
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3. Is
. L.___A_. 1 ..._- - J transporting edmployeeslIn5 hecourseeo theire rsmployment example:employeener
} } }
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
. 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
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LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Silver 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 LOAD TYPE