HomeMy WebLinkAbout2025-00030532 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
I011011000 l III
ilfi ft IOU
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003816795
u, 1 U21 3 4 1 U1 2 U2 1 U, 1 1_12 1 U, 1 U2 1 1 12 U, 13 U2 11 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S 0$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY El OVER 91,500 El NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
El AMENDED
YR 202512025-00030532 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 r1
® ❑ RELATED ®V ❑N 05 14 2025 ®AM ❑YES ®NO U1 -<
E CHICAGO ST Elgin08:04
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FT/MI N E S W N GROVE AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 15 Co
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 MUSS 0 uuv 0!Cy 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
0 2 !
yr 13-UNDER CARRIAGE U I !!. 2 FIRE 0 IE <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 0 U2 m
F 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 _
❑N DUNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6, i�6 ji COM VEH 0 Ea 1
0
0
F. Elgin IL 60123 B 1 DQ72579 IL FIRST CONTACT 11 7_: __5 *Ilsees.See Sidebar U1
REAR
c Z E
TELEPHONE
IL D 1 FM H K8D80CG B04264 Safeway Ins Co ❑v ®N r
U2 M
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 3829204-I L-PP-005 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Refused ❑Y El 2 c
N DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMV 0 NCv 0 DV
!1 9 y 71 Jeep(after 19681�rokee 2015 00-NONE 11_-j t2----
DUE TO CRASH ❑ 2 x
o 13-UNDER CARRIAGE 10'i !., 2 FIRE ID ® U2 C
F 2 4 SYSTEM IN ENGAGED 15-OTHER 9 1,6-TOPO3 * X
❑Y El ElUNK VEH. AT CRASH 99-UNKNOWN Distraction Value
0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6-iI 6 i_.,_4 COM VEH ❑ ® U1 CO
FIRST CONTACT 3 7 _, _5 •(ryes,See Sidebar
. LE GIN Z IL 60123 0 1 EA27618 IL 2025 REAR C
M
IL D 1 C4PJ LCB1 FW539372 State Farm ❑Y J N RDEF 73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 1747974-SFP-13 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND 0 N U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
E/ MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ®Y U2 Z
N 1 El 11 1 05,14 l2025 08 04 ®❑pM in a Work Zone? ❑N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 ❑ 20 99
N 3 ❑ 0 CITATIONS ISSUED 0 PENDING + ! ❑PM ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 3
-a, ARREST NAME / / El PM '
oN ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLAT
r 2 ❑ ARREST NAME AM
T 1 r ❑❑PM ®Unknown work zone type
U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 D ❑AM Workers present? ®Y 30
414-Lara. Saul 07 , ! ❑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.
. 0
r ----r••--, A CMV is defined as any motor vehicle used to transport passengers or property and: Z
r I
1. Hasaor more thanpounds(example:truck or truck trailer 1. Hasaweight rating10,000 -I
INDICATE NORTH tan) p0
BY ARROW 2 Is used or desi nedtotran ortmorethan15 C
g sp passengers including the driver
II \
r r r (example:shuttle or charter bus):or
3. is tlesgnetl to car 15 or fewer passengers and operated a contract carrier O
- } } } transporting employees In the courses of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or w
4. Is used or designated to transport between 9 and 15 passengers,including rCjt
I. } } } g Po passen rs,includi the driver,
ill
Not To Scale l for direct compensation(example:large van used for specific purpose):or O
L i t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
placarding(example:placards will be isplayed on the vehicle).
I>
CARRIER NAME Z
ADDRESS 'n
V)
UNt 2 n
,( `r.... CITY/STATE/ZIP g
-s _ i. i. i. MOTOR CARR.ID 0 Interstate 0 Intrastate
t- 0 Not in Comm./Govt. 0 Not in Comm./Other 00
-- USDOT NO. ILCC NO. C
m
XI
Source of above z
. Form Number
m
Xl
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIM 1 m
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
Gray Gray
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 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE