HomeMy WebLinkAbout2025-00023496 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
I01101100 0111111
1 III Oil
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003793943
u, 1 U21 1 1 1 U1 8 U2 1 u,99 u2 1 U1 99 U2 99 1 12 ut 13 U2 1 �K P 0119
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-$1.500 ®ON SCENE 10
VEHICLE/PROPERTY ®OVER$1,500
El NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and f or Tow Due To Crash YR 20255120255-00023496 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 16 m1055 N LIBERTY ST El In 12:17
® ❑ RELATED ❑Y ®N 04 14 2025 ❑AM ❑YES ®NO U1 -<
_ _ g PRIVATE mo !day!yr ®PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 2 Co
❑ FT!MI N E S W Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEOAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 0
FOR DAMAGEDAREA(S) FROM TOWED U1 I�
Colvin. Hermond.T. 1 2 /
yr 13-UNDER CARRIAGE 101 �. 2 FIRE 0
IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 3 <<T1
M 9 4 Y SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 9 ALGN =
❑ ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ iI 6 �i 4 COM VEH ® 0 1 0
F. FIRST CONTACT 1 7 --. _;__5 *IIYes.See Sidebar Ut
Z Cherry Valley IL 61016 0 1 0 P843CD GA 2025 Is
TELEPHONE
IL D 7 1 NPCX4EX6LD673709 Zurich American Insurance ❑Y Il N U2 ni
19 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Miller Pipeline LLC BAP-1497588-01 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
14 (,�j
N DRIVER 0 PARKED 0 DRIVERLESS ❑ PED 0 PEDAL 0 EWES 0 uv 0 NCv 0 CIRCLE NUMBER(S) U1
Dv
/1 9 8 4 Chevrolet Silverado 2005 00-NONE 'o,1 t2 c,�2 FIRE DUE ID
CRASH 0 ® U2 2 C
...
13-UNDER CARRIAGE
c
M 9 4 SYSTEM IN ENGAGED 15-OTHER 911,6•TOP 3 9 0 X
❑Y ❑N 0 UNK VEH. AT CRASH 99-UNKNOWN *0istraction value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 'i ®- 6 il;, COM VEH ❑ u1CO
FIRST CONTACT 8 QJ__,l�_5 •If Yes.See Sidebar C
Z Cary IL 60013 0 1 0 3888487B IL 2005 REAR 0 Si)
D
IL D 0 1GCEC14X55Z102651 Progressive ❑Y ®N RDEF 73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 994380078 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(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 04,14 l2025 12 17 ®pm in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
0
2 0 20 99 1 / ❑PM ❑Construction *
1
Z 3 0 I!!I CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
a 1 ® 11 1 ❑
ARREST NAME Colvin. Hermond.T. 11-709-D 273004170 / ! El PM SLMT
o N 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME Utility
AM
7t 2 ❑ 1 1 ❑❑PM 0 Unknown work zone type U1
ARREST NAME
n OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 30
273-Tucker.Craig 200 334-Fries , / ❑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••--, , i ; A CMV is defined as any motor vehicle used to transport passengers or property and: lIto
i- }-----I--_--, I f combination):. Has or more thanpounds(example:truckortrucktrailer 1. Hasaweight rating10,000 -<
INDICATE NORTH p0
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
A (example:shuttle or charter bus):or
3. Is desgned to carry 15 or fewer passengers and operated by a contract carrier I O
Mat To Scare J } } transporting employees In the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
L i.-----}----; i L - } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver, C
for direct compensation(example:large van used for specific purpose):or
KEEP7AVE
L L____a____.: _ t ii. , 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
1 seiplacarding(example:placards will be displayed on the vehicle). ;p
0 1 L i. i. ..... .....
CARRIER NAME Miller Pipeline LLC Z
ADDRESS 8850 CRAWFORDSVILLE RD
Io
w
I ,
I _ i. i. i. i. MOTOR CARR.ID El Interstate 0 Intrastate
l I ❑ Not in Comm./Govt. ❑ Not in Comm./Other 0
N.71.16 s,raet _ USDOT NO. 240106 ILCC NO. m
XI
Source of above z
. xi
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z
own tank)? 0 Yes ® 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 ®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
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE