HomeMy WebLinkAbout2025-00029414 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Of 2 Sheets 01111101111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 7
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and f or Tow Due To Crash YR 202512025-00029414 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 m
824 E CHICAGO ST Elgin11:19
® ❑ RELATED ❑Y ®N 05 09 2025 ®AM ❑YES ®NO U1 -<
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW Cl)
❑ FT!MI N E S W Cook HIT ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 -I
&RUN
❑ 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 0
0 1 /
yr 13-UNDER CARRIAGE IE
10l !!. 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 m
M 2 SY4 ❑Y ONM❑UNK VEH. 0 AT CRASH IN 0 is-OTHER
99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR0
F. POINT OF $ iI �i 4 COM VEH 0 0 1 0
FIRST CONTACT 1 7_;,B-_;__5 *Yves.See Sidebar Ut
Z GLENDALE HEIGHTS IL 60139 0 1 0 359980D IL 2025 REAR
TELEPHONE
IL D 1GBOG2CA5E1106803 Protextice Insurance Comp El ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
Fed Ex IL56-V0018642 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
98 0
0 DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMV 0 NCv 0 DV
yr 12 _ 71
o 13-UNDER CARRIAGE 10 I c. 2 FIRE ❑ ❑ U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 916-TOP 3 ❑ 0 SPDR 0
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN POINT OF 8 *Oistracton Value 0 -
4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT TA—'-'1:-5 •CIO e1sVSee SidebarEH ❑ ❑ U1 C
CO
F` pEAR •
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M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O
❑Y ❑N RDEF X
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) (SEATI (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) 0
/ / U2 r
m
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0
EV MOST EVNT LOS DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 43 5 Mobile 1 Auto Repair Shop Red Concrete Pole 05,09 /2025 11 19 ®❑pM AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 70
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
v t 2 ❑ 824 E CH ICAGO ST ELGIN IL 60120 10 99 , ! ❑AM ❑Construction *
Z3 ❑ ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2
-a, ARREST NAME / / ID PM
o N 1 ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
SLMT
10
t 2 ❑ ARREST NAME AM
7 1 r ❑❑pM ❑Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y
-
2 3 ❑ ❑AM Workers present? ❑
1545 VanEycke. Brier 302 , , ❑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••--, , 4 A CMV is defined as any motor vehicle used to transport passengers or property and: Z
N 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer
ii combination):or —I
r , r INDICATE NORTH 77
Not To Stele BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
824?E9Chicago?St _ (example:shuttle or charter bus):or 0
A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
t } } transporting employees in the course of their employment(example:employee
,..,` transporter-usually a van type vehicle or passenger car):or w
-----------; �. t } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver,
Q
o "-'-,/ for direct compensation(example:large van used for specific purpose):or O
I-____a____. i i. t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
.D
placarding(example:placards will be displayed on the vehicle). XI
—1
/ CARRIER NAME Z
/ ADDRESS O
T.
rn
� .. CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate 5
I I . I ❑ Not in Comm./Govt. Not in Comm./Other
❑ 0
----------1 - USDOT NO. ILCC NO. m
PCI
Source of above z
.* 0 Yes 0 No ❑ Unknown 0
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' m
TRAILER 1 ❑ ❑ 0 z
ri
TRAILER 2 ❑ 0 0 o
u 1 COLOR U_COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO:
_ 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