HomeMy WebLinkAbout2025-00032465 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S 1215501-51.500 ®ON SCENE 1
VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT)
0 AMENDED ElB Injury and/or Tow Due To Crash YR 202512025-00032465 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r7
NATIONAL ST Elgin 07:53
® ❑ RELATED I81 Y 0 N 05 22 2025 ®AM ❑YES ®NO U1 -<
g PRIVATE mo /day/yr ❑PM FLOW CONDITION I17
FT N E S W WELLINGTON AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR El SLOW 1 (n
❑ Kane HIT ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
El AT RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
FOR DAMAGEDAREA(S) FROM TOWED U1 I�
Kevin. B. 0 1 /
yr 13-UNDER CARRIAGE ,I :: FIRE 0
NI
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0U2 2 (T7
M 2 4 SYTM❑Y ®SNEDUNK VEH. 0 ATCRASHD 0 99-U 15-UNKNOWN THER9 16•TOP 3 `Distraction Value 9 ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i�s 4 COM VEH ❑ j$J 1 0
~ ELGIN I L 60120 0 1 0 FIRST CONTACT 12 7_: __5 *IIYes.See Sidebar Ut
Z CZ63027 IL 2024 REAR
TELEPHONE
IL D 0 WBAPK7G56BNN86628 NIA ❑Y ❑N U2 I'
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Smith.Tiffany. N. NIA 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 2 eu
p; DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES O NIAV 0 i v 0 Dv CIRCLE NUMBER(S) U1
/2 0 0 0 Chevrolet Trail Blazer 2025 00-NONE 'o,� t2 (,-2 FIRE DUE D CRASH ® U2 2 xj
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o mo 13-UNDER CARRIAGE
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F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 1 S .t. 4 COM VEH ❑ ® Ut CO
F,,, FIRST CONTACT 6 O7 ,�=Q)OS •IfYes.See Sidebar C
ELGIN IL 60120 0 1 0 EN71320 IL 2025 i Si)0
IL D 0 KL79MPSL8SB059796 State Farm ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Myriam.Chisco 3460496-SFP-13 BAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP 996 <
Refused RESPONDER U1 =
iUPIIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
2 4 11 /
2 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 05,22 /2025 07 53 ®❑pM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
0 2 ❑ 03 18 / / ❑PM ❑Construction *
R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
- U2
a, ARREST NAME Spates. Kevin. B. 11-601 1540-W220 / / ❑❑PM ❑Maintenance SLMT
U 1 ® 1 1 1 igi CITATIONS ISSUED ❑PENDING MT
o N SECTION CITATION NO. ROAD CLEARANCE TIME
El AM ❑Utility
t 2 D ARREST NAME Spates. Kevin. B. 3-414 1540-W219 05/22 /2025 06 30 ®PM ❑Unknown work zone type U1 15
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ 1540-Allah. Muhammad 401 275-Engelke / / 0 PM Workers present? ®N U2 15
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.
A CMV is defined asmotor vehicle used to transportand:
r ----,5-••--, ; any passengers or property
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1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
} i.-- -i-- --; } } } r -, , ; ; , 1, ( INDICATE NORTH combination):or —I
p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ' i 1 , } (example:shuttle or charter bus):or
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3. Is
. L.___A_. . ..._- - . transporting edmployeeslin5 hecourseeo theire rsmployment example:employeener
} } }
transporter-usually a van type vehicle or passenger car):or co
< <.__-a-_-_, , l• < <--_-a-___� , , , , 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 0
L L___-a____.: L L L ...._-..:_____� t i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). XI
--I
CARRIER NAME Z
ADDRESS 0
T.
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other O
USDOT NO. ILCC NO. m
XI
Source of above z
Were HAZMAT placards on vehicle? 0 Yes 0 No =
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 g
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. w
Gray Red
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 0 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