HomeMy WebLinkAbout2025-00030384 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 1111111I HH 11111 11111111110000000001HH1�111E11
DRAG TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003616803
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INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 7
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00030384 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED ®Y 0 N 05 13 2025 DAM ❑YES ®NO U1
N MCLEAN BLVD Elgin 04:15
g PRIVATE mo /day/yr ®PM FLOW CONDITION M
•
FT!MI N E S W ILLINOIS PKWY COUNTY PROPERTY ❑ ® N DOORING® DOORING ICIy #OF MOTOR 0 SLOW 1 cn
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C)
0 8 /
yr 13-UNDER CARRIAGE IE
10l ! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ]$I U2 0 171
F 2 4 15-OTHER
❑Y ®N
SYSTEM
❑UNK VEH. 0 AT CRASH D 0 99-UNKNOWN 9 16•TOP 3 ,Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 iI S ii,4 COM VEH ❑ j$J 1 0
~ ELGIN I L 60120 0 1 0 FIRST CONTACT 6 7_;LQ-_5 *Ir Ves.See Sidebar Ut
Z EW53825 IL 2025
TELEPHONE
IL D 0 JN8AZ08T73W109876 American Alliance ®Y 0 N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same I LAA-0804059-02 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y ® N 9 2 eu
m x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEOAL 0 EWES 0!My 0 NCV 0 DV
/1 9 7r 7 Nissan Altima 2015 00-NONE 11_"j Q1-_, DUE TO CRASH ❑ 2
0 13-UNDER CARRIAGE 10( ) 2 FIRE ID ® U2 C
le c ®
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y NJ N DUNK VEH. AT CRASH 99-UNKNOWN `0istrac8Dn Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-iI�1:, If Yes.See Sidebar-4 COM VEH ❑ ® U1 CO
FIRST CONTACT 12 7 _, .5 •
H ELGIN IL 60123 0 1 0 AF55332 IL 2019 I 0 C
M
IL D 0 1 N4AL3AP8FC105097 American Family ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Other 99 9 Same 1942-7300-02-60-FPPA BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused E Y°®N 9 u1 =
(UNIT) (SEAT) (DOBI (SEX) (SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
1 6 03 /
D
/ / 3 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 5 05,13 /2025 04 15 ®pm 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 ❑ 30 99
N 1 3 ❑ CITATIONS ISSUED 0 PENDING + / ❑PM• El Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 7
-a ARREST NAME / / ID '
o u ® 11 5 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility SLMT
,
10
n 7 El 2 ARREST NAME AM
, , ❑❑PM El Unknown work zone type U1
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ 1531-SchEmbach.Jack 601 391-Jacobucci , , ❑❑AM Workers present? ®N U2 10
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 I 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -
`-- --I-- --' 0 '" - ( INDICATE NORTH combination):or -I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
I I _ } (example:shuttle or charter bus):or
Not To Scale r 7
- ------I----; - —— — - transportingtl ned to a1ln the course of 5 or fewer rye r rs and example:employee
a contract der
• t Femployeesemployment
■'. s,. . ]-` transporter-usually a van type vehicle or passenger car):or co
L L.___a__-_.l rat Unh2 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or O
flllnbe?Parkway 'D
_ < 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires I,
a . i. L placarding(example:placards will be displayed on the vehicle).
CARRIER NAME Z
ADDRESS 0
O
CITY/STATE/ZIPg
MOTOR CARR.ID 0 Interstate 0 Intrastate
I r I ❑ Not in Comm./Govt. Not in Comm./Other
------------ - USDOT NO. ILCC NO. rn
XI
Source of above z
. ❑ Yes 0 No 0 Unknown M
Did Carrier Safety Regulations MCS)violation contribute to the crash? A
❑ Yes No ❑ 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'; 0 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 0 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: 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/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE