HomeMy WebLinkAbout2025-00024025 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets II III H II II 1Dlii
01100
01111111�11��1 nil
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003790088
u1 9 u21 2 4 1 U1 9 U2 1 U1 1 U2 1 U199 U2 1 1 13 U,23 U2 1 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY ❑$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 1
VEHICLE/PROPERTY ®OVER$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00024025 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 �I
MAY ST Elgin12:34
® ❑ RELATED ®Y 0 N 04 16 2025 ❑AM ❑YES IX]NO U1 —<
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION MFT l MI N E S W CLEVELAND AVE COUNTY PROPERTY ❑Y ® N DOORING ICIy #OF MOTOR 0 SLOW 5 Cl)
❑ Cook 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
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
/ / FOR DAMAGEDAREA(S) FRO r TOWED U1 0
Unknown Unknown Unknown 00-NONE it.. 12 , OUETOCRASH ❑ EN
NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE IE
10 ! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 rn
SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3
1 3 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN Distraction Value ALGN 2
$ 4 COM VEH 0 ZgJ
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF it S �i1 0
I— 0 9 FIRST CONTACT 5 7 ;—--_;_OS •Y Yes.See Sidebar U1 0
c REAR
Z
E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 11/
Unknown ❑Y ❑N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same Unknown 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF`Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
.5D Y°N❑l N Al
m N DRIVER 0 PARKED 0 DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 lily 0 i v 0 Dv
!1 9 8 1 International CRIRCE34 2021 00-NONE ,t_' 12.._, DUE TO CRASH 0 C 7 xi
0Yr 13-UNDER CARRIAGE 10 I 2 FIRE ❑ ® U2 C
c ij
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 016•TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF (Di.�!,_4 COM VEH D ® Ut CO
FIRST CONTACT 9 7 _,L_5 •• •It Yes.See Sidebar C
ELGIN IL 60124 0 1 0 103887SB IL 2024 Si)0
7 4DRBUC8N7MB192473 Illinois Counties Risk Ma ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
U-46 P41001458242501 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
2 7 0 5 / M 1 3 0 1 0
7 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 04,16 /2025 12 34 ®FM in a Work Zone? ®N DIRP co
1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 ❑ 20 30
3 3 0 0 CITATIONS ISSUED 0 PENDING + / 0 PM• El Construction
SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM ❑Maintenance U2
—a, ARREST NAME / / ID PM '
o N ® 11 1 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT
99
r 2 ARREST NAME AM
7 1 / ❑❑PM El Unknown work zone type U1
El
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
❑Y 30
350-Farrell. Heather 401 275-Engelke / / ❑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
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
Y Not To Scale ( combination):or
INDICATE NORTH —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver n
} - (example:shuttle or charter bus):or
' A I I } 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O
} } transporting employees In the course of their employment(example:employee
0 ; transporter-usually a van type vehicle or passenger car):or CO
L L.___a____.I If - - C
4. Isusedordesinatedtotrans rtbetween9and15 ssen rs,includingthedriver,
I . ' i } } } for direct compensation(example:large van used for specific purpose):or
L L--_-a----. — — — — r-s.,r , - 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
U121 D
Tr i• i• i. i• .i. CCITY/STATElZIP AIER NAME
Z
n
V)
I ADDRESSRR '
MOTOR CARR.ID 0 Interstate ElO Intrastate 5
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
-"--------1 - USDOT NO. ILCC NO. rn
XI
Source of above z
. ❑ Yes 0 No 0 Unknown M
D
Did Carrier Safety Regulations MCS)violation contribute to the crash?
❑ 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' 0 Yes 0 No 2
TRAILER VIN 1 m
co
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
Yellow
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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BYlT6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE