HomeMy WebLinkAbout2025-00025055 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100 VI H 111100011
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INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED YR 202512025-00025055 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
N MCLEAN BLVD Elgin10:31
® ❑ RELATED ®Y 0 N 04 21 2025 ®AM ❑YES El NO U1
_ _ g PRIVATE mo !day/yr ❑PM FLOW CONDITION III
FT l MI N E S W TODD FARM DR COUNTY PROPERTY ❑Y 21N DOORING Ely #OF MOTOR El SLOW 1 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N 51 FREE FLOW # LNS 0
g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 NW 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 5 C)
FOR DAMAGEDAREA(S) FRONT TOWED U1 Q
Wienckowski.James.J. 1 0 /
yr 13-UNDER CARRIAGE 10.I !�. 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED THER ❑ 0 U2 5 M
M 2 4 SYTM❑Y ®S NE❑UNK VEH. 0 AT CRASH 0 15-99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s ii_6 I, 4 COM VEH 0 g 1 0
f. FIRST CONTACT 11 7_:—__;__5 *II Yes.See Sidebar U1
Z Aurora IL 60506 0 1 0 DK65087 IL 2025 REAR
TELEPHONE
IL D 0 4S4BSAFC9K3368247 Geico ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 6151491922 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 XI
g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 iiuv 0 i v 0 Dv
!1 9 5 1 Subaru Forrester 2023 00-NONE 111
1�I t2 (,_2 FIREO CRASH rg ® U2 C 2
o — 13-UNDER CARRIAGE
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 X
❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN O *0istraetlon Value 9 0
POINT OF s-.;, i.t.4 COM VEH ❑ ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6
FIRST CONTACT Jr 7 —_,SOS •ItYes,See Sidebar
Union IL 60180 0 1 0 ES16891 IL 2026 REAR
0 N
IL D 0 JF2SKACC5PH458273 Allstate ❑Y ®N RDEF Xl
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
99 9 Same 912362090 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER
U1 =
(UNIT) (SEAT) (DOBI (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
2 3 09 / M 2 3 0 1 0
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/ / #OCCS D
/ / U1 1 D
/ / 2 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 4 04,21 l2025 10 31 ®❑AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 2
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
0 2 ❑ 23 99 , , ❑PM ❑Construction *
5
R 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
o1 ® 11 4 ARREST NAME Wienckowski.James.J. 11-904-C 1538-000240 , ! ❑PM SLMT
o N
u ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' ❑Utility
10
r 2 ARREST NAME AM
7 El r ❑❑PM ❑Unknown work zone type U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 10
1538-Estrada. Leticia 500 397-Jones 06 ,03,2025 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.
r ----r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
i•____r____; ® 1 Has awe)ghtratingmorethan10,000pounds{ xamp :truckortrucktrailer -<
1.
e le
I ; INDICATE NORTH P3
IBY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
L L ; Not To Scale _ (example:shuttle or charter bus):or C
II L*-1:
3. Is designed to carry 15 or fewer passen ers and o rated a contract carrierpa OL.___A.._.� y } } } transport) em to eesInthecourseoftheir emenPlogeyr
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< <.___A____, Todd7Farrn7Dr� I I I4. Is� �sedordesi natedtotransehrtbetween9ad c5)t(ssen plrs, rtclrrdmgthe driver, C
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for direct compensation(example:large van used for specific purpose):or 0
L L--_-a-....l — — lira - l. i. I i. 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
11 placarding(example:placards will be displayed on the vehicle).
—Id\ I ~ ry I - CARRIER NAME —I
ADDRESS
III
CITY/STATE/ZIP g
II I MOTOR CARR.ID 0 Interstate ❑ Intrastate
I r I I I ❑ Not in Comm./Govt. Not in Comm./Other
❑ 0
; _Y_ _..; USDOT NO. ILCC NO. m
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 g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash? A
❑ Yes II No 0 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
0
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 ❑ ❑ 0 Z
ill
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Bronze Green
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 2 TOWED BY/TO.
SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE