HomeMy WebLinkAbout2025-00022388 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
01101100 00 IV 0100 III
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XO03784805
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INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 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 3
VEHICLE/PROPERTY ®OVER$1,500
El NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00022388 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 m® ❑ RELATED PRIVATE ❑Y ®N 04 09 2025 ❑AM ❑YES ®NO U1 -<
BIG TIMBER RD Elgin mo /day/yr 05:11 ®PM FLOW CONDITION m
E050 0/MI N 0 S w North RANDALL Rd COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 15 u)
Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD IN STOPPED U2 --I
El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
gi DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EOUES ❑uuv ❑ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 5 0
0 3 /
yr 13-UNDER CARRIAGE 10 12 !. 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 Ea U2 5 M
M 2 SY is-OTHER
4 ❑Y ®SNE❑UNK VEH. 0 AT CRASH M IN D 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S__;i L S 4 COM VEH 0 Ea 1 0
F. FIRST CONTACT 12 7 —, _5 *Irves.See Sidebar Ut
Z ST CHARLES IL 60175-4610 0 1 0 EY80516 IL 2025 REAR
TELEPHONE
IL D 0 1J4FY19SXVP460997 ALLSTATE El ®N U2 13 . nri
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
co
99 9 KRISTOFER.JON. N. 811264333 2 m
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2
g DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED 0 PEDAL 0 EWES 0 NW 0 i v 0 Dv
2 Yr 0 0 0 Ford Escape 2013 00-NONE 1 t2 c 2 FIRE DUE O CRASH D ® U2 2 C
o 13-UNDER CARRIAGE
c
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X
❑Y ®N DUNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value 9 0
POINT OF S i 4 COM VEH D ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 5
FIRST CONTACT 6 07 ,�=QI:OS C.
If Yes,See Sidebar C
BATAVIA IL 60510 0 1 0 DR54640 IL 2025 FIRSTSi)0
IL D 0 1 FMCUOJ94DUD22701 STATEFARM ❑y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 MRBN ENTERPRISE LLC 0239812-SFP-13 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE;ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((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 41 ,12 ,25 05 11 ®PM AM in a Work Zone? ®N DIRP D
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1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
o"
2 ❑ 28 99 + ) ❑PM• ❑Construction *
R 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM 0 Maintenance U2
-a, ARREST NAME KRISTOFER.VINCENZO. R. 11-601-Ax 1551000046 / ! El PM SLMT
® 11 1 0 CITATIONS ISSUED ❑PENDING Utility•
o N 1 SECTION CITATION NO. ROAD CLEARANCE TIME El
t 2 El ARREST NAME 41 r 12 125 05 15 ®PM 0 Unknown work zone type U1 0 AM 45
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 45
1551-Dede.Joseph 502 391-Jacobucci 51 , 31 ,025 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.
r ----r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
N 1.c mHaS weigh`rating more than 10,000 pounds(example:truck or truck trader -<1. Hasa
` --I -' [Big7l1rnber?Rd) INDICATE NORTH tlon).o
BY ARROW 2 Is used or designed to transport more than 15 C
,G/// g sp passengers including the driver
} r r r (example:shuttle or charter bus):or
._.; Not 7b Mars]
3. Is desgned to carry 15 or fewer passengers and operated by a contract carrier O
-----I-- - transporting employees In the course of their employment(example:employee X
_———— t } transporter-usually a van type vehicle or passenger car):or
C.
} }
L }-----}----; l - } } 4. Is used or designated to transport between 9 and 15passengers,including the dryer,
J r for direct compensation(example:large van used fors cific purpose):or
L L____a____� ___ __ ` _ t i I L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires O
placarding(example:placards will be displayed on the vehicle). XI
2:.__
CARRIER NAME —I
Z
ADDRESS 0
ot Iry 1 w
CITY/STATE/ZIP 0
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
--- --1 - USDOT NO. ILCC NO. rn
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
m
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 Black
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 0 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/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE