HomeMy WebLinkAbout2025-00022450 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 4 Sheets 01111101111 011011000 0 111 lI IOU lID
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0O3809342*
u, 9 u21 1 1 1 U,1 U U2 1 U199 u2 1 U,99 U2 1 5 12 u, 2 U2 1 *P 0119*
INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY 0 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 2025I 2025-00022450 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 f1
® ❑ RELATED ❑Y ®N 04 09 2025 DAM ❑YES ®NO U1
S STATE ST Elgin11:57
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT N E S W HARDING ST COUNTY PROPERTY ❑Y ® N DOORING ❑Y #OF MOTOR 0 SLOW 14 u)
❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
/ ! FOR DAMAGEDAREA(S) FROftf TOWED U1 0
Unknown.0. Unknown Unknown 00-NONE ,, • 12 DUE TOCRASH ❑ VI E
NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE ) ! FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 'O 2 <
9 9 SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 DISTRACTED 0 ]� U2 =
❑Y ON ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 9 ALGN
6 4 COM VEH 0 0
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _,I[6 !i,_ 1 00
~ 0 9 0 FIRST CONTACT 1 7_; _5 *II Yes.See Sidebar Ut
REAR
2 Z ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1
,6 9 Unknown ❑Y ❑N U2 I-
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same Unknown 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
'‘.3D Y°N❑l N 0
m N DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMy 0 KCv 0 Dv
!1 9 5 5 Freightliner Gc$�120 2007 oo-NONE O, . 12.._1 DUE TO CRASH ❑ Ig► 21
Ti Yr 13-UNDER CARRIAGE 2 FIRE 0 21 U2 C
M 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X
0 Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN `Oistracton Value 9 g
I II 4 COM VEH 14 ❑ Ut to
CONTACT 1
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF
O 8
Y . s 1 .5 •(ryes,See Sidebar C
— Port Lucie FL 34953 0 1 0 PWW9045 OH 2025 I 0 Si)
Z D
FL A 7 1 FUJBBCK77PX14418 ACE American Insurance Co ❑Y ®N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 Same M MTH 10845774 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (0081 (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 El 11 1 04,09 /2025 11 58 ®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 �
2 0 04 13
N 3 0 0 CITATIONS ISSUED 0 PENDING + ❑PM, El Construction
SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
—a, ARREST NAME / / ❑PM '
ou ® 11 3 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT
t 2 ❑ ARREST NAMEAM
'El
1 / ❑❑PM ®Unknown work zone type 30
U1
n OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 30
447 Collins, Dominique 701 / , ❑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
CD:
ADDITIONAL UNITS FORMS.
r ----r••--, 'A I A CMV is defined as any motor vehicle used to transport passengers or property and: Z
J I l 1' V.: J 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -
c ' ' OelaSt r INDICATE NORTH combination):or .Z�1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
1' 1 _ (example:shuttle or charter bus):or
T r r r X
` ` A ..ii I 3. Is desgned to carry 15 or fewer passengers and operated by a contract carder O
I } } } transporting employees in5 the course of their employment(example:employee 0
transporter-usually a van type vehicle or passenger car):or w
L Y r 4. Is used or designated to transport between 9 and 15 passengers,including C}--- ----; - } } } g po passen rs,includi the driver,
f' for direct compensation(example:large van used for specific purpose):or O
L i.____a____.I n _ I. I IIII._ 5. Is any vehicle used to transport any hazardous material(HAZMAT)thatrequires
-t placarding(example:placards will be displayed on the vehicle). XI
,1' I' CARRIER NAME Forward Air Z
HerdInp73t _ __ ADDRESS 6700 PORT RD O
II' vi
f CITY/STATE/ZIP Groveport)OH!43125 o
I C
l l MOTOR CARR.ID Interstate Intrastate
I ` ` ❑ ❑
I 00
. Not in Comm./Govt. Not in Comm./Other
1 r - USDOT NO. 728630 ILCC NO. C
m
8.98trsto?8t 73
Source of above z
. IDOT PERMIT NO. WIDELOAD-; ❑Yes ®No =
TRAILER VIN 1 1 UYVS2531 EG766639 m
to
LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 ® 0 0 Z
TRAILER 2 0 0 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 53f ft. 2 ft. w
White
u 1 TOWED TOTAL VEHICLE LENGTH 63ft ft. NO.OF AXLES 3
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 9 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. 3 CARGO BODY TYPE 9 LOAD TYPE 5