HomeMy WebLinkAbout2025-00024697 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
01101100 IVI
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XOp37„2227-
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INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT 0 A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ❑OVER 51,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 202512025-00024697 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 �I
S MCLEAN BLVD Elgin 12:43
® ❑ RELATED ❑Y ®N 04 19 2025 ❑AM ❑YES ®NO U1 -<
_ _ PRIVATE mo /day/yr ®PM FLOW CONDITION M
FT!MI N E S W BOWES RD COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 1 (n
❑ Kane HIT ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
® &RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUCE 0 NIAV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0
0 5 /
yr 13-UNDER CARRIAGE 10l I�. 2 FIRE 0
NI
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 4 rn
M 2 4 SYTM❑Y ®S NE❑UNK VEH. 0 AT CRASH 99-UNKNOWN THER9 76.70P 3 *Distraction Value 9 ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF i, a 4 COM VEH 0 Ea 1 C)
~ ELGIN I L 60124 0 1 0 FIRST CONTACT 00 O7 _: _-5 *If Yes.See Sidebar U1 0
Z3015470B IL 2026
TELEPHONE
IL 0 1 FTEW1 EGXG FA90149 Progressive ❑Y Igl N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 27598300 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y El 2 0
p; DRIVER 0 PARKED 0 DRIVERLESS ❑ PED 0 PEDAL 0 EWES 0 MAV 0 NOV 0 DV CIRCLE NUMBER(S) U1
/1 9 8 7 Toyota Camry 2020 00-NONE ,."1 Q1,O DUE TO CRASH 0 21 2 x
o 13-UNDER CARRIAGE 1a) f. 2 FIRE 0 ® U2 C
c
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 s_i�L COM VEH ❑ ® U1 CO
FIRST CONTACT 12 Y��_, =5 •)ryes.See Sidebar C
ELGIN IL 60123 0 1 0 EN47756 IL 2026aR 0 N
IL D 0 4T1 G 11 AK1 LU877168 AM ERICAN ALLIANCE ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Same I LAA094281802 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOE) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
1 3 08 /
LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
u ® 9 1 04/19 /2025 12 43 0 AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
2 ❑ 10 99
N 1 3 0 CITATIONS ISSUED 0 PENDING ( ( _ 0 PM- ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM 0 Maintenance U2
-a, u ARREST NAME / / ID PM '
1 ® 19 1 UtilitySLMT
o SECTION CITATION NO. ROAD CLEARANCE TIME El
❑CITATIONS ISSUED PENDING
r 2 El ARREST NAME 04/19 /2025 12 43 ®PM El Unknown work zone type U1 El AM
35
n T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 - ❑AM Workers present? ❑Y 35
1526-Walsh.Jacob 701 / / ❑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
} }----------i 1 - INDICATE NORTH combination):or more than pounds(example:truck or truck/trailer
1. Has a weight rating10 000
I ?Mclean?BI BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} } - r r r (example:shuttle or charter bus):or 0
' A / \ 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
- } } } transporting employees in the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or co-- 2 } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver,
for direct compensation(example:large van used for specific purpose):or O
L i.____a____.: I _ 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). ,Zmt
- —I
r CARRIER NAME Z
Bowee7RD I ADDRESS 0I I V)
_ ArOr TO Stale_; ()
r CITY/STATE/ZIP g
I - MOTOR CARR.ID 0 Interstate El Intrastate
r r O
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
�"---- --: - USDOT NO. ILCC NO. rn
XI
Source of above Z
. • m
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 M
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
co
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 0 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Black Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE