HomeMy WebLinkAbout2025-00030889 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 01101100001111111100111I 0
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X463823712*
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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 1215501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and f or Tow Due To Crash YR 202512025-00030889 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m
N STATE ST El In 05:22
® ❑ RELATED ❑Y ®N 05 15 2025 ❑AM ❑YES ®NO U1
g PRIVATE mo !day!yr ®PM FLOW CONDITION m
01090,MI N E S W West Highland AveCOUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 2 rn
® g Kane HIT&RUN ®Y ❑ N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ® FREE FLOW # LNS 0
18:DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
! !
FOR DAMAGEDAREA(S) FRONT TOWED U1 O
Unknown.0. Hyundai Kona 2018 00-NONE 0 >2 �/DUE TOCRASH ❑ EN
NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 10.I 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED U2 4 <
M 9 9 SYSTEM IN O ENGAGED 0 15-OTHER 9 16.TOP 3 ❑ _
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 9 ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8, iI 6 '�.4 C.OM VEH 0 El 1 0
~ 0 1 0 FIRST CONTACT 12 7_; __5 *uYes.SeeSidebar U1
Z DR44362 IL 2025 ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1
KM8K3CA50JU165130 unknown ❑Y ❑N U2 I—
M
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Jeffries.Armond unknown 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Refused ❑Y ® N 99 0
x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAv 0 Ncv 0 DV
�y !1 9 5 9 Nissan Frontier 2018 00-NONE ,._"j t2..-_, DUE TO CRASH ❑ 2 73
o 13-UNDERCARRIAGE 10;1 2 FIRE ❑ ® U2 C
II
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP
3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `0istrac on Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8
i 6 ....4 COM VEH D ® u1 CO
FIRST CONTACT 5 7 -�'O6 •(ryes,See Sidebar C
ELGIN IL 60123 0 1 0 3816053B IL 2025 I 0 fp
IL D 0 1 N6ADOER7JN735799 Progressive ❑Y ®N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 3816053B BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (D081 (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)r(A.DDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
U1 1 D
/ / 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
u 1 ® 11 1 5/ ,5/ ,025 05 22 ®PM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
2 ❑ 28 03
N 3 ❑ ❑CITATIONS ISSUED 0 PENDING + ! ❑PM• ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5
—a, ARREST NAME / / ID PM '
o N ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
SLMT
30
r 2 ARREST NAME AM
7 1 r ❑❑PM ❑Unknown work zone type U1
D
n OFFICER ID SIGNATURE BEAT!DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ - ❑AM Workers present? ❑Y 30
1547-Steele.Justin sot , ! ❑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 -<
i- }---.r----; Mt1 } INDICATE NORTH combination):or —I
_ p1
; BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
. + - } (example:shuttle or charter bus):or
X
3. Is designed to carry15 or fewer passengers and operated a contract carrier O
}_---------i ll ` }} } transporting employee in the course of their employment(example:employee
enger car):or X
co
i. }---__I.,..---' Not To Scale I'I - } } } •transporter sed or des gnated to transport betweelly a van type vehicle or n 9 and 15 assen passengers,including the driver. N
I --- N for direct compensation(example:large van used fors cific purpose):or O
i unzz
__ _ t i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D
Q placarding(example:placards will be displayed on the vehicle). XI
CARRIER NAME Z
I _ _ _ ADDRESS O
w
CCITY/STATE/ZIP0g
I - MOTOR CARR.ID 0 Interstate 0 Intrastate
I I -I- I ❑ Not in Comm./Govt. 0 Not in Comm./Other
�I. ------1 - USDOT NO. ILCC NO. rn
XI
Source of above z
. If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. Xl
Xl
Did HAZMAT spill 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 M
D
Did Carrier Safety Regulations MCS)violation contribute to the crash?
❑ Yes II No ElUnknown 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 White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 2 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