HomeMy WebLinkAbout2025-00030130 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003632646
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT 0 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 51,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 2025I 2025-00030130 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 m® ❑ RELATED PRIVATE ❑Y ®N 05 12 2025DAM ❑YES E)NO U1 -<
S RANDALL RD Elgin mo /day/yr 02:37 ®PM FLOW CONDITION M
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 15 u)
00-5 FT/0 N E O W South St WITH VEHICLES INVLD 0 STOPPED U2 --I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑Y ® N PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0 NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0
NT
NAME(LAST,FIRST,M) Sullivan.James. P. mo yr
Kia Motors Co rento 2016 00-NONE 0• O 0 ®TOWED U1 O
DUE TO CRASH ❑
13-UNDER CARRIAGE FIRE ❑ IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED 0 Ea U2 4 M
M 2 SYTM IN ENGAGEDTHER
8 ❑Y ®SNE❑LINK VEH. O AT CRASH O 99-Uis-UNKNOWN 9 16-TOPO `Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 it 6 i'I�COM VEH 0 Ea 1 C)
H 1- ELGIN I L 60124 K 1 0 FIRST CONTACT 12 T_: -06 •I(Yes"See Sidebar U1 0
ZZ932522 IL 2026 REAR
TELEPHONE
IL D 0 SXYPHDA57GG143914 Liberty Mutual ❑Y ®N U2 1—
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 99 9 Same AOS2480718604057 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER
/1 9 8y 3 Ford Explorer 2023 00-NONE ,j_' 12.._, DUE TO CRASH ❑ C 2
.. 13-UNDER CARRIAGE 1a 1 r. 2 FIRE 0 ® U2 C
c
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 016-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `OistractIon Value 9
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF ) 6 l!- COM VEH ❑ ® Ut CO
FIRST CONTACT 9 7 _, _6 •)ryes.See Sidebar C
Z ST CHARLES I L 60175 0 1 0 EA82179 I L 2025 FIRST
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D
IL D 0 1 FMSK8DH1 PGA99653 State Farm ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
Elgin Fire 99 9 Sarullo.Vito 2005243SFP13 BAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE;ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEXI {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((A.DDRESS)((TELEPHONE) (EMS) (HOSPITAL)
W 06 /
LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y
N 1 ❑ 11 1 05,12 /2025 02 37 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
453. 2 ® 11 1 17 99 05,12 /2025 02 38 PM
1 ® , ❑Construction >F
3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM Maintenance U2
❑
—a ARREST NAME 05/12/2025 02 41 ®pM "
,
1 ® 11 1 ElUtility
0CITATIONS ISSUED ❑PENDING SLMT
o uSECTION CITATION NO. ROAD CLEARANCE TIME
t 2 0 ARREST NAME 05/12 /2025 11 10 0 PM El Unknown work zone type 0 AM U1 45
n T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 45
1515-BellEck.Stacy 702 334-Fries , / ❑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" 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 truckrtrailer -<
' I•--_.r-_--; _ INDICATE NORTH combination):or
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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 carry 15 or fewer passengers and operated by a contract carrier I O
- ------I----; ; - ii . I- . transporting employees in the course of their employment
pbyment(example:employee
transporter-usually a van type vehicle or passenger car):or w
L L.___a._._.l 4. Is used ordesi natedtotrans rtbetween9and15passengers,indudingthedrrver,
�® } } } •
for direct compensation(exam :large van used for speific purose):or
I. I_ __I_-____I I - t . ii. L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
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placarding(example:placards will be displayed on the vehicle). m
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t./ -•.------. CARRIER NAME Z
t ADDRESS 0
—_.— V)
1
j CITY/STATE/ZIP I g
- I. MOTOR CARR.ID 0 Interstate 0 Intrastate
I r_.. ❑ Not in Comm./Govt. ❑ Not in Comm./Other
0
-1 I I I USDOT NO. ILCC NO.
M
Not Tb Scats I I I
Source of above z
.
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 ®No 2
TRAILER VIN 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
0
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
White Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE