HomeMy WebLinkAbout2025-00028346 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
M0110110000111 110001110
DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X003809741
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT El A 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 El NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
El AMENDED
YR 202512025-00028346 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
2 S JACKSON ST El In06:11
® ❑ RELATED ❑Y ®N 05 05 2025 ®AM El YES ®No u1 -<
_ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ® N DOORING ❑Y #OF MOTOR ❑SLOW Cl)
❑ FT/MI NESW Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD DO
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❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS O
Qg3 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 2 0
0 3 FOR DAMAGEDAREA(S) FRO TOWED U1 Q
NAME(LAST,FIRST,M) Stein,William mo / 2 0 0 9 f T Porsche Boxter 986 201 3 00-NONE 0 12 7T DUE TO CRASH ® ❑
yr �3-UNDERCARRIAGE ) !!.�Z:/ FIRE ❑ al
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 0 U2 m
M 2 SY n is-OTHER
4 ❑Y ElM DUNK VEH. AT CRASH IN n D 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN 2
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r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, it s �i COM VEH ❑ El 3 0
0
ELGIN I L 60120 B 1 0 FIRST CONTACT 11 7_;1 __5 *lIYes.See Sidebar U1
Z DA66000 IL 2023 REAR
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED
5 ( 0 WPOCB2A85DS133192 State Farm ❑Y ®N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 99 9 Stein,Andrew, E. 0145022-SFP-13 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF`Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER
2 ou
❑ DRIVER 0 PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMV 0 NOV 0 DV CIRCLE NUMBER(S) U1
yr 12 _ C1
o 13-UNDER CARRIAGE 10.i t, FIRE ❑ ❑ U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 9,16•TOP3 ❑ ❑ SPDR 0
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistractlon value U1 3 -
POINT OF s-.;, 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 8 . :-5 COM•I sVEH See •Sidebar❑ ❑ C
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M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O
❑Y ❑N RDEF73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
BAC
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
RESP❑YD❑N NDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0
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EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ❑ 36 1 Keysor,Charles Damage to retaining wall 05/05 ,2025 06 12 ®❑pM AM 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 ❑ 1 2 2 S JACKSON ST ELGIN IL 60123 19 05 05,05 ,2025 06 12 PAA
1 ❑ • ❑Construction *
r' 3 IN43 5 El CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME
z J ®AM ❑Maintenance U2
-a, ARREST NAME Stein.William 11-708-B 742254 05,05 r2025 06 15 ❑PM SLMT
o u 1 0 •B!CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
o N AM 30
t 2 ElARREST NAME Stein.William 11-708-B 742255 , , 0 PM 0 Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME ❑Y
AM Workers present?
2 3 0 ®
471-Evans, Lakysha 601 331-Ziegler 05 ,28,2025 09 00 ❑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
e3 / ADDITIONAL UNITS FORMS.
r l----r•---, .;, ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
i
�-
—; `-W ^---_ 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer
•� - combination):or
i- !____Y____l I. _ I.
INDICATE NORTH
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
i_ ; _ (example:shuttle or charter bus):or
s�s�» ar T,
------ 1'elr<7 rr
I- I- . 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
�.__-A-. _ , } } . transportingemployees In the course of their employment
pbyment(example:employee_i____ transporter-usually a van Type vehicle or passenger ca)orCL L____a.._.; 4. Is used ordesi natedtotrans rtbetween9and15 ssen rs,includingthedriver,1.-1:
} } } for direct compensation(example:large van used for specific purpose):or
---_- ,r ax.,rrx m
< .....I. - _ i i L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
j,h . placarding(example:placards will be displayed on the vehicle). m
Rx ;0
R$ CARRIER NAME —I
ADDRESS 0
CITY/STATE/ZIP 0
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� n
' 8 1 MOTORCARR.ID 0 Interstate El
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❑ Not in Comm./Govt. 0 Not in Comm./Other
} '.----Y_. rn.vr a.max Not To ' : i. : USDOT NO. ILCC NO. <
Seale • , • • X1
Source of above z
'
. IDOT PERMIT NO. WIDELOAD-; ❑Yes 0 No =
TRAILER VIN 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U_COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Adieu/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET
U_DUE ETOO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO:DUE T VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE