HomeMy WebLinkAbout2025-00025173 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00379 221
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑$501-51.500 ❑ON SCENE I
VEHICLE/PROPERTY ®OVER$1,500
®NOT ON SCENE(DESK REPORT)
❑AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00025173 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 -n
VILLA ST Elgin 04:53
® ❑ RELATED ®Y 0 N 04 21 2025 ❑AM ❑YES ®NO U1
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION ITT
FT!MI N E S W ILLINOIS AVE COUNTY PROPERTY ElY ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEON. 0 EWES ❑uuv ❑!Cy ❑ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
/ / FOR DAMAGEDAREA(S) FROr4T TOWED U1 Q
Unknown Unknown Unknown 00-NONE ,, • 12 DUE TOCRASH ❑ VI
NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 101 ! 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ]$I U2 2 I'T1
SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3
9 9 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $_iL a i 4 COM VEH 0 Ea 1 0
FIRST CONTACT 1 7_;—__;__5 *II Yes.See Sidebar Ut
0 9 0 UNKNOWN REAR
2 Z
_ TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1
UNKNOWN Unknown ❑Y ❑N U2 I'
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Unknown. Unknown Unknown 1 rn
`5 HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
99 0
m g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑ru,ly 0 Ncv ❑Dv
/1 9 yr 5 Jeep(after 19 a t•}legade 2019 00-NONE O,' t2 "_, DUE TO CRASH ❑ p'� 2
13-UNDER CARRIAGE 10 I 2 FIRE 0 ® U2 C
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN `OistractIon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-iI�1:, 4 COM VEH ❑ ® U1 W
FIRST CONTACT 11 7�_, _5 •(ryes.See Sidebar
= ELGIN IL 60120 0 1 0 W-253802 IL 2025
IL D 0 ZACNJABB4KPK32019 Allstate ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 811287174 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
iUNIT) (SEAT) (DOBI (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(A.DDRESS)1(TELEPHONE) (EMS) (HOSPITAL)
2 4 08 /
:A
/ / UI 1 D
/ / 3 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 1 04/21 /2025 05 50 ®pm 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 U1
2 0 20 05
N 3 0 0 CITATIONS ISSUED ID PENDING • + / ❑PM• ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 7
-a ARREST NAME / / ❑PM '
o N ® 11 1 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility SLMT
,
30
t 2 ARREST NAME AM
7 / / ❑❑PM 0 Unknown work zone type U1
El
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 - ❑AM Workers present? ❑Y 30
489-Reynolds.Allison 400 / / ❑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 -<
` ` ' ' I r INDICATE NORTH combination)or .Z�1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ (example:shuttle or charter bus):or
IX
- ------I----; transporting employeened to slin the course 5 or fewer passengers
rhea emaployment nd operated
xample:employee
transporter} } }
♦_ 6ransportet-usually a van type vehicle or passenger car):or c0
L L.___a__. ` 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or 0
L L.._-a____. — — — — — — — — - 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
Z
CARRIER NAME Z
,• s.; __ ADDRESS 0-1 fl X _N� . w
CITY/STATE/ZIP 0
IMOTOR CARR.ID 0 Interstate 0 Intrastate
, ❑ 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 M
D
Did Carrier Safety Regulations MCS)violation contribute to the crash?
❑ Yes II No 0 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 VIM 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
0
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
White Gray
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 DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE