HomeMy WebLinkAbout2025-00026144 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X463600413
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 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 14
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
El AMENDED ElB Injury and for Tow Due To Crash YR 202512025-00026144 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 —n
TODD FARM DR El In03:37
® ❑ RELATED ®Y 0 N 04 25 2025 ❑AM ❑YES El NO U1 -<
g PRIVATE mo !day/yr ®PM FLOW CONDITION m
FTlMI N E S W N MCLEAN BLVD COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 Cl)
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) 0 0
Y N
0 9 !
yr 13-UNDER CARRIAGE VI
O i FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14--UTOTAL(ALL) 2 DISTRACTED 0 0 U2 2 m
F 2 4 ❑Y ®SYSNEM IN❑UNK VEH. 0 AT CRASHD 0 99-OTHER
056.70P 3 ,Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF Dail �'.4 COM VEH 0 0 1 0
F. FIRST CONTACT 3 7 B--___5 *rives.See Sidebar U1
Z Algonquin IL 60102 0 1 0 NADYNE IL 2025 I ;
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1/
° ( 0 2G 1 WA5E33C1135627 State Farm ❑v Igl N U2 m
IS EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 1147634-SFP-13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
73
Refused ❑Y ElN 2 0
p; DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0!My 0 NCv 0 DV
!1 9$3 Pontiac G6 2006', 00-NONE 0. Q1-_, DUE TO CRASH ❑ 2 73
0 13-UNDER CARRIAGE 10( I 2 FIRE 0 ® U2 C
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M 2 4 ❑Y ®SYSTEM IN 0 ENGAGED 0 ®-OTHER 9,16-TOP 3 9 0 X
N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s 6 �1:, 4 COM VEH ❑ ® U1 CO
FIRST CONTACT 12 TA_IL5 •Ifyes,See Sidebar
Z ELGIN IL 60120 0 1 0 DK51204 IL 2023 I 0 C
IL D 0 1G2ZG558764286658 United Equitable ❑Y ®N RDEF 73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same ILU006188 BAG $
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 4 41 ,51 /025 03 37 ®pm in a Work Zone? ®N DIRP co
1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 3 C)
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2 0 2 06 ) / ❑PM ❑Construction *
Si r' 5 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME
❑AM 0 Maintenance U2
-, 1 ® 11 4 ARREST NAME Michalik. Nadyne. L. 11-801 1531000043 / ! El Pm SLMT
o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
0 AM
r 2 ❑ ARREST NAME 41 1 51 1025 04 37 ®PM 0 Unknown work zone type U1 3O
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 40
1531-SchEmbach.Jack 501 51 , 31 /025 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
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
` ` --I -' • INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
` Not To Scale II Ii. e. (example:shuttle or charter bus):or
e�nwee nerve 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I
A O
} } } transporting employees in the course of their employment(example:employee X
y a van type
< <. __.� N I.�..� I I 1 transporter sed or des II designated to transpicle or ort between 9 and 15 passengers,ssen rs,including the dryer, w
E I 1 } } } for direct compensation(example:large van used for specific purpose):or O
< __ -( I I i 5. Is anyvehicle used to transport anyhazardous material(HAZMAT)that requires D
v placarding P placards P Y ).
Wcartli (example: will be displayed ed on the vehicle XI
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ii I rj 1 - _- CARRIER NAME Z
Todd'lFrm9Dr ID .. i. i. i. ADDRESS D
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• ow
CITY/STATE/ZIP
_ MOTOR CARR.ID 0 Interstate ❑ Intrastate
I I T I I I 0 Not in Comm./Govt. Not in Comm./Other
0
—lir I
USDOT NO. ILCC NO. C
I XI
Source of above Z
. 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' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 ❑ o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. 0
Black Black
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/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE