HomeMy WebLinkAbout2025-00029097 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 011011000 l 110
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT El No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑5501-51.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and f or Tow Due To Crash YR 202512025-00029097 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 m341 WILCOX AVE El In10:16
® ❑ RELATED ❑Y ®N 05 07 2025 ❑AM ❑YES El NO U1 -<
g PRIVATE mo /day/yr ®PM FLOW CONDITION m
_
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 cn
❑ FT/MI NESW 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 t] PARKED O DRIVERLESS 0 PED CI PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C)
FOR DAMAGEDAREA(S) FROf'tr TOWED U1 Q
Wilson.Courtne D. 0 9 /
yr (2)13-UNDER CARRIAGE FIRE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED ® 0 U2 0 m
F 2 SY is-OTHER
5 ❑Y ®SNE DUNK VEH. 0 AT CRASH M IN D 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value 5 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ :i1 S 4 COM VEH 0 j$J 1 0
F.
ELGIN I L 60123 0 1 0 FIRST CONTACT 12 7_; __5 *II Yes.See Sidebar U1
Z BH71674 IL 2025 E
TELEPHONE
IL D 0 1 C4NJ PFA8H D202911 Insure on the spot ❑Y Il N U2 19 . m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 99 9 Same I LT5787696 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER XI
Refused 0 Y ® N 2 0
0 DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMv 0 KCV 0 DV
yr
Ti 13-UNDER CARRIAGE 10 i -
z FIRE 0 El U2 C
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR C)
a SYSTEM IN 0 ENGAGED 0 15-OTHER 9..16-TOP 3 X
❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN `Distraction value g 9
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 9,1� 4 COM VEH 0 ® U1 W
F,,, FIRST CONTACT 7 74a�1=5 •IfYes.SeeSidebar
CQ69498 IL 2025 REAR 0
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
9BWDE61JX54019061 Progressive ❑Y ®N RDEFXI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Megicanos.Victor 958867875 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
u1 =
)UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) OM (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 18 1 05,07 /2025 10 16 ®AM in a Work Zone? ®N DIRP co
I I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
v 2 0 28 15 05,07 /2025 10 31 ®PM 0 Construction
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1
R 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
J ❑AM ❑Maintenance U2
a1 ® 11 1 ARREST NAME Wilson.Courtney. D. 11-601 S1553-000051 05/07/2025 10 35 ®pM SLMT
o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility
0 AM
r 2 0 ARREST NAME 05/07 /2025 11 09 ®PM 0 Unknown work zone type U1 20
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 20
1553-Jentsch.Clarissa 701 05 ,27,2025 09 00 0 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••--, , N . A CMV is defined as any motor vehicle used to transport passengers or property and: z
U 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
i- }---.r----; INDICATE NORTH combination):or
Not p,
To Scale BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- } (example:shuttle or charter bus):or
X
L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
} } } transporting employees in the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
L L.___a__. 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver,
PQ ( P 9 PQ or 0
L a t i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D
a placarding(example:placards will be displayed on the vehicle). ,Zmt
- I CARRIER NAME Z
ADDRESS D
Mill1 ! fA 1
No CITY/STATE/ZIP 0
g
MOTOR CARR.ID 0 Interstate ❑ Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
-"--------1 - USDOT NO. ILCC NO. rn
XI
Source of above z
. 0 Yes 0 No ❑ Unknown 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'; ❑Yes 0 No 2
TRAILER VIN 1 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 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Black Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE