HomeMy WebLinkAbout2025-00026097 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Of 2 Sheets 01111101111 101101100��0 �011010000100
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003797713
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INVESTIGATING AGENCY DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
El AMENDED ElB Injury and/or Tow Due To Crash YR 202512025-00026097 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 7 m
® ❑ RELATED ®Y 0 N 04 25 2025 ®AM ❑YES ®NO U1 -<
BIG TIMBER RD Elgin11:21
g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FTlMI N E S W JANSEN FARM DR COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 2 Cl)
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD DO
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 0 PEDAL 0 eaves 0 NW 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
yr
Mack Trucks. IOcanite 2009 NONE „ 12 , DUE TO CRASH ❑ ENE
13-UNDER CARRIAGE 10 t.i 2 FIRE 0IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 1 O DISTRACTED 0 0 U2 4 M
M 2 SYTM IN ENGAGE4 ❑Y ®SNE❑UNK VEH. O ATCRASHD 0 99-UNKNOWN 9 16•TOP 3 `Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 ij 6 �i COM VEH ® 0 1 0
~ PLANO IL 60545 0 1 0 FIRST CONTACT 2 7_• -_5 *I(Yes.See Sidebar Ut
Z 52658TZ IL 2024
7 TELEPHONE
IL A 7 1M1AX07Y39M005646 ROBERTSON RYAN ❑Y ®N U2 I''I
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
99 9 WINNINGER EQUIPMENT A3323359 2 m
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
20 0
p; DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 r uv 0 i v 0 Dv
!1 9 yf 2 General MotorSiQJEp 2015 00-NONE ,�_1 t2-- , DUE TO CRASH ❑ C 2
o 13-UNDERCARRIAGE 10;I 2 FIRE ❑ ® U2 C
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER
9 16•TOP 3
❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 ,ii 6 1' COM VEH D ® U1 W
I— FIRST CONTACT 5 7 _�_i C.
It yes.See Sidebar C
ELGIN IL 60123 0 1 0 488625D IL 2024 REAR0 N
IL D 1GT424E83FF668351 RESOURCE INSURANCE ❑Y ®N RDEF M
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
99 9 Same 5260087300 BAc E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER
u1 =
(UNIT) (SEAT) (DM (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 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 04,25 r2025 11 21 ®❑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 �
O 2 ❑ 05 05 , r ❑PM ❑Construction *
<<v 3 0 lyg CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM 0 Maintenance U2
—a, ARREST NAME BRUSVEEN. MAXWELL. K. 11-709-A W1554-000040 r ! ❑PM SLMT
1 ® 11 1 0 CITATIONS ISSUED ❑PENDING Utility
o N SECTION CITATION NO. ROAD CLEARANCE TIME 0
AM u, 35
r 2 ❑ ARREST NAME 04 r 25 r2025 11 21 [�PM 0 Unknown work zone type
x T
n OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 35
1554-Wagener.Vincent 502 - r r ❑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.
A CMV is defined asmotor vehicle used to transportand:
r ----,5-•"--, ; any passengers or property
Z
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
} i.-- -i-- --; } } } r -, , ; ; , ; ( INDICATE NORTH combination):or —I
p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ' i 1 , } (example:shuttle or charter bus):or
X
3. Is L L.___A_. 1 <""_"� J transporting employened to es Inhecourse 5 or fewer o their eers mplod yment example:employeener X
} } }
transporter-usually a van type vehicle or passenger car):or co
F <.___a__"_, , F < <-"_"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____. 1 L L ....__.�____. . . 7 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). m,Zt
` CARRIER NAME WINNINGER EQUIPMENT LLC Z
ADDRESS 1211 DEER ST 0
T.
CITY/STATE/ZIP YORKVILLE I IL 160560 n
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
❑ Not in Comm./Gout. ❑ Not in Comm./Other O
USDOT NO. ILCC NO. m
XI
Source of above z
. If Yes,Name on placard 0
4 digit UN NO. 1 digit Hazard class No. XI
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?
❑ Yes II No ElUnknown 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'7 ❑Yes ®No 2
TRAILER VIN 1 1 M1AX07Y39M005646 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 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 72 ft. 2 ft. w
Red Black
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES 7
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 0 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 0 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. 6 CARGO BODY TYPE LOAD TYPE