HomeMy WebLinkAbout2025-00030655 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 011011000 00 111111110H
DRAC TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X003619065
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INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑5501-51,500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 202512025-00030655 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH -n
333 S MCLEAN BLVD Elgin06:21
® ❑ RELATED ❑Y ®N 05 14 2025 ❑AM ❑YES ®NO U1 -<
_ PRIVATE mo /day/yr ®PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 2 fA
❑ FT/MI NESW Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
0 DRIVER ❑ PARKED ❑DRIVERLESS N PED ❑PEDAL 0 EWES 0 NOV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 n
1 2 /
yr
13-UNDER CARRIAGE 10 i 2 FIRE 0 NI
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED0 U2 2
El
m
M 1 3 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 _
❑N ❑UNK VEH. AT CRASH 99-UNKNOWN $ 4 `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF a �I COM VEH ❑ Ea 1 c Z ELGIN IL 60120 A FIRST CONTACT 00 7_; _5 *I1 ves.See Sidebar U1
0
REAR
TELEPHONE
IL ❑Y 0 N U2 19 . m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 1 55 1 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER XI
Provena St.Joseph ❑Y ® N 0
E{ DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL ❑EWES ❑Nov ❑Ncv 0 DV
!1 9 8 5 Ford F350 2005 00-NONE 0' t2..-_1 DUE TO CRASH ❑ ! l 24 x
o 13-UNDER CARRIAGE 10 I c. 2 FIRE ❑ U2 C
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 19-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistractlon Value 9 0
POINT OF 8 i1�i-4 COM VEH ❑ ® U1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 15 Y B .5 •(ryes.See Sidebar
= Elgin IL 60120 0 1 0 203210F IL 2025 REAR O C
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IL D 1 FTWX32Y35EC70991 PEKIN ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire 1 Same 006214859 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (DOBi (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(A.DDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
2 3 06 /
LOC. DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y
Z
N 1 El 12 1 05/14 /2025 06 21 ®PM in a Work Zone? NJ DIRP D
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YE$Check One below:
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
v 2 2 99 051 14 /2025 O6 21 ®PM ❑Construction >F
1
<w ❑ xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
3 ❑AM ❑Maintenance U2
o1 ® 12 1 ARREST NAME Deloncker, Barry. K. 11-1007 S1553-000055 05/14/2025 06 24 Igi pM SLMT
S' N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility
t 2 El ARREST NAME 05/14 /2025 08 13 ®PM ❑Unknown work zone type U1 0 AM
45
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ 1553-Jentsch.Clarissa 701 391-Jacobucci 06 ,24/2025 09 00 0 PM Workerspresent7 ®N U2 45
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
} }____r____; I I 1. Has a_ combination)ght rating more than 10,000 pounds(example:xamp .truck or truck trailer:or
® } INDICATE NORTH
1 1 i BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i_ .:.. -:. .....j I
t I 1 - } f f (example:shuttle or charter bus):or 0
_ Not To Scale
L A 4—, } } 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier 0
} transporting employees In the course of their employment(example:employee X
— — transporter-usually a van type vehicle or passenger car):or w
-- ~
_ } } } 4. Is used or designated to transport between 9 and 15 passengers,including the driver, '
for direct compensation(example:large van used for specific purpose):or O
Li NAu!? -D
a
} } } 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). XI
♦ r CARRIER NAME Z
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+'---i E - i. MOTOR CARR.ID ❑ Interstate ❑ Intrastate
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Unit/2 P ❑ Not in Comm./Govt. ❑ Not in Comm./Other 0
, --- --1 `d - USDOT NO. ILCC NO. C
m
XI
Source of above z
. 0 Yes iJ 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 VIM 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 ❑ ❑ 0 Z
1-1
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Black
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO:
SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE