HomeMy WebLinkAbout2025-00022885 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets _ 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XL03784218
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ❑ON SCENE 7
VEHICLE/PROPERTY ®OVER$1,500
®NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and f or Tow Due To Crash YR 202512025-00022885 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m
1325 BLUFF CITY BLVD Elgin04:02
® ❑ RELATED ❑Y ®N 04 11 2025 ❑AM ❑YES ®NO U1 -<
_ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR ❑SLOW 7 Cl)
❑ FT/MI NESW Cook HIT ®Y ❑ N WITH VEHICLES INVLD ❑ STOPPED U2 --I
&RUN
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Q83 DRIVER I] PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
/ / FOR DAMAGEDAREA(S) FROPtf TOWED U1 0
Unknown.O. Unknown Unknown 00-NONE 'It. 12 , OUETOCRASH ❑ EN
NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 10 !!. 2 FIRE 0 ® <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 m
SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3
M 9 9 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN =
$ 4 COM VEH 0 ZgJ
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _,I[B !i,_ 1 00
~ 0 9 FIRST CONTACT 99 7_; _5 *IIYes.See Sidebar U1
REAR
2 Z ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1/
Unknown ❑Y ❑N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same unknown 9 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ❑ N 99 0
0 DRIVER X. PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 iiuv 0 i v 0 DV
yr Volvo VNL 2016 00-NONE 12..-_, DUE TO CRASH ❑ 21 98 �7
o 13-UNDER CARRIAGE o I 2 FIRE 0 ® U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 0 DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 0 ® SPDR 0
❑Y ❑N DUNK VEH. AT CRASH 99-UNKNOWN *Oistrac on Value 9 U1 9 -
POINT OF s ) `4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR �}._ C.OM VEH ❑ 27 CO
F„ FIRST CONTACT 11 7 -5 •If Yes.See Sidebar
P930377 IL REAR 0 Si)
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
4V4NC9EH9GN932425 Hub International ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 99 =
99 9 BTS Transport WF016275 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (008) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME))(ADDRESS)/(TELEPHONE! (EMS) (HOSPITAL)
U2 0
996
/ / m
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/ / U1 1 D
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EV MOST EVNT DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N ® 18 9 04/11 /2025 04 00 0 AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U,
2 0 18 18
N 3 0 0 CITATIONS ISSUED 0 PENDING + / 0 PM• ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 7
z
-a ARREST NAME / / ElPM '
o u ® 11 5 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT
,
ARREST NAME AM
Tr 2 ❑ ❑❑PM 0 Unknown work zone type U1
/ 1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ 547-Hometer.William 401 360-Yucaitis / / ❑❑PM Workers present? ®N U2 10
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.
Bluft?Cltf?Bvd .
r ----r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
c ` --I -' r INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
Pew - (example:shuttle or charter bus):or 0
BWR'I Ib?Blvd 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O
`----------i ® Unit2 - } } } transportingemployees in the course of their employment
pbyment(example:employee X
I _ , transporter-usually a van type vehicle or passenger car):or w
--i .`""""`jI.
} } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver, C
for direct compensation(example:large van used for specific purpose):or
L i l. 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
—1
CARRIER NAME Z
ADDRESS 0
C)
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
I r ❑ Not in Comm./Govt. 0 Not in Comm./Other
----------1 - USDOT NO. ILCC NO. m
XI
Source of above z
0 Yes 0 No ❑ Unknown A
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
Silver
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT: 9 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE