HomeMy WebLinkAbout2025-00030331 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 011011000 l III 1110001100
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003616754
u, 9 U2 1 1 1 U1 8 U2 1 U,99 1_12 U,99 U2 1 1 9 U1 1 U221 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S El$501-$1,500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ElB Injury and/or Tow Due To Crash YR 202512025-00030331 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 f1
® ❑ RELATED ' ' 0 N 05 13 2025 ®AM ❑YES ®NO U1 —<
DUNCAN AVE Elgin11:41
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION ITl
FT l MI N E S W CONGDON AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 3 Cl)
❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I
CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ® FREE FLOW # LNS 0
g DRIVER I] PARKED D DRIVERLESS 0 PED 0 PEDAL 0 EDUCE 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
/ / FOR DAMAGEDAREA(S) FROr4T TOWED U1 0
Unknown.0. Unknown Unknown 00-NONE 11,• 12 DUE TOCRASH ❑
NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 101 !!. 2 FIRE 0 IE <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 M
9 9 ❑Y SYSTEM IN ENGAGED 15-OTHER 976.TOP
�3 _
ID N ❑UNK VEH. AT CRASH 99-UNKNOWN Distraction Value ALGN
S COM VEH 0 Ea
T. CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF i� S �I1 0
I— 0 1 0 FIRST CONTACT 1 7 _�-_;_( •If Yea.See Sidebar Ut 0
c Z REAR
E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1
Unknown ❑Y ❑N U2 I—
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same Unknown 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
r D Y°®N 0
0 DRIVER I} PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 M/v 0 NCv 0 DV
yr Ford Transit Connect 2019 00-NONE 1i_ 12._ DUETO CRASH 0 ® 14 73
13-UNDER CARRIAGE I FIRE ID ElU2
Ti
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10' f O DISTRACTED 0 ® SPDR 0
0 0
SYSTEM IN ENGAGED 15-OTHER 9.19-TOP 3 9
a NJ Y N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value
POINT OF Sit "4 ut
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR _ l.'._ C. VEH ❑ ® CO
FIRST CONTACT 2 Y _, _5 •IfYes.See Sidebar
H 3601107B IL I 0 t;p
M . STATE CLASS COL ID VIN INSURANCE CO. EXPIRED U2 0
NMOLS7F22K1415369 Erie ❑Y ®N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Chesterfield Awning Q090740056 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (D051 (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
W 1 0 /
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 18 1 05,13 /2025 11 48 ®❑pM in a Work Zone? ®N DIRP co
1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 0 20 99
N 3 0 ❑CITATIONS ISSUED ID PENDING / ❑PM El Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 5
—a, ARREST NAME / / ❑PM '
o N 1 ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT
30
r 2 0 ARREST NAME AM
7 1 / ❑❑PM 0 Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 - ❑AM Workers present? 0 Y 30
350-Farrell. Heather 102 r / ❑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 -<
c ` --I -' r INDICATE NORTH combination):or .Z-1
Not To Scale BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i_ JO N - } (example:shuttle or charter bus):or 0
I- <-----I----; transporting employeened to slin the course 5 or fewer passengers
then emaployment nd operated
xample:employee
transporter T T + } } }
transporter-usually a van type vehicle or passenger car):or co
L L.___a__ 4. Is used ordesi natedtotrans transport passengers,including C} } } g po passen rs,includi the driver,
tee„nN,,, for direct compensation(example:large van used for specific purpose):or O
L i - - - - - - L i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D
placarding(example:placards will be displayed on the vehicle). XI-I
, ,. ,.
i i - CARRIER NAME Z
ADDRESS '
T.
/Z
o naave.uncer , (7
I4.
CITY/STATE/ZIP 0
MOTOR CARR.ID 0 Interstate 0 Intrastate
I r ❑ Not in Comm./Govt. 0 Not in Comm./Other
-----------1 - USDOT NO. ILCC NO. rn
XI
Source of above z
. • m
Did HAZMAT spit from vehicle(do NOT consider FUEL from vehicle's z
own tank)? 0 Yes 0 No 0 Unknown
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes 0 No 0 Unknown g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash? A
❑ Yes II El Unknown C
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 VIM 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
White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
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/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE