HomeMy WebLinkAbout2025-00033180 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 011011000 h0 0 HIDRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0036312 +
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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 1215501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00033180 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 71
1061 N LIBERTY ST Elgin08:46
® ❑ RELATED ❑Y ®N 05 24 2025 ❑AM ❑YES ®NO U1
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION MCOUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ FT/MI N E S W Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 02 8
FOR DAMAGEDAREA(S) FRONT TOWED U1
Unknown.0. ! ! Chevrolet Silverado 00-NONE Q•
�i 0 DUE TOCRASH ❑ EN
NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 10.I 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 02 m
9 9 SYSTEM IN 9 ENGAGED 9 15-OTHER 916.70P 3 _
❑Y ElN ®UNK VEH. AT CRASH ®-UNKNOWN `Distraction Value 9 ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF & i�s 4 COM VEH 0 0 4
0
Z 0 9 0 T92H852 IN FIRST CONTACT 12 7_; __5 *uYes.See Sidebar Ut
REAR
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 4 D Unknown ®Y ❑N U2 I-
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same Unknown 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF`Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y ❑ N 99 0
�{ DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 m v 0 i v 0 DV
a$ !1 9 9 2 Honda Civic 2018 00-NONE i1_FR"j 12'-_, DUE TO CRASH ❑ 2 73
0 13-UNDER CARRIAGE 1U'I 2 FIRE 0 ElU2 C
c
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistracton Value 9 9
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. & 1 S .. 4 OM V ® Ut COF,,, STATE YEAR POINT OF
FIRST CONTACT 6 O,�=Q i)OS C•IfYes.SeeEH Sidebar❑ C
ELGINZ IL 60120 0 1 0 CN51082 IL 2025aR Si)0
M
IL A 7 19XFC2F59JE025987 State Farm ❑Y ®N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
99 9 Same 0458205-SFP-13 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND O N u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 CO 11 9 05,24 /2025 08 46 ®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 �
2 0 18 18
N 3 0 ❑CITATIONS ISSUED 0 PENDING + ❑PM• 0 Construction
SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM 0 Maintenance U2
—a, ARREST NAME / / ❑PM
1 ® 1 1 1 0 CITATIONS ISSUED 0 PENDING • UtilitySLMT
o N SECTION CITATION NO. ROAD CLEARANCE TIME 0
t 2 0 ARREST NAME 05 t 25 l2025 08 46 ®PM El Unknown work zone type U1 0 AM
35
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ID ❑AM Workers present? ❑Y 35
1543-Sturgeon. Kyle 200 391-Jacobucci , / ❑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
Has a weight rating more than 10 000 pounds(example:truck or truck/trailer
Iii 1. a le:
} }---_r__--; } combination):or
INDICATE NORTH P1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} L i i r� .Qc - } ,. ,. (example:shuttle or charter bus):or 0
�'
% .� 3. Is designed to carry15 or fewer passengers and operated a contract carrier O
- -----A---.-I 4
, - } } } transporting employee in the course of their employment� � (example:employee � X
< <.___a____� I - } } } 4alsuorter-sedordesgnatedto transport betweelly a van type vehicle or n9 and 15r rpassen rs,includingthedriver,
C
f for direct compensation(example:large van used for specific purpose):or O
L t l. I I 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
i
placarding(example:placards will be displayed on the vehicle). ,Zmt
- -71 I. I• I• I-- --I-
CARRIER NAME -I
ADDRESS
0
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I
Kno?Are D
n
CITY/STATE/ZIP
- MOTOR CARR.ID 0 Interstate 0 Intrastate
1 1 r Not To Scale ❑ Not in Comm./Govt. Not in Comm./Other 00
i- --- '-4, - 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 g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash? A
❑ Yes II El 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'; ❑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' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Silver Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 9 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