HomeMy WebLinkAbout2025-00034225 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Df 2 Sheets _ 01111101111 011011000 flifi I 101 110
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 10
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ElB Injury and for Tow Due To Crash YR 202512025-00034225 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 21 �I
® ❑ RELATED ®Y 0 N 05 29 2025 ®AM ❑YES ®NO U1 -<
N STATE ST Elgin 10:15
_ _ g PRIVATE mo !day!yr ❑PM FLOW CONDITION m
FT!MI N E S W W H I G H LAN D AV E COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ® STOPPED U2 —I
Igl AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0
0 3 !
yr 13-UNDER CARRIAGE 16 IE
1 I�. 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 4 rn
M 2 4 ❑Y IN NE M IN ENGAGED
DUNK VEH. 0 AT CRASH 99-OTHER WN 9 16•TOP 3 ,Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ i� 6 �r.4 COM VEH I1 0 1 C)
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Rapid City SD 57703 0 1 0 421710 SD FIRST CONTACT 5 7_:REAR-OO Yes.See Sidebar U1 0
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TELEPHONE
SD A 7 4V4NC9EHORN657496 Arch Insurance Comp. El ❑N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
H &M Trucking Inc zacat3330107 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
21 (,0j
6U DElVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑ uv 0 Ncv ❑DV
!1 9 6 1 Ford Explorer 2016 00-NONE ,�_' t2.._, DUE TO CRASH ❑ C 273
omo y Yr - 13-UNDER CARRIAGE 10 i 2 FIRE ❑ ® U2 C
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 016•TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF I 6 i,,_ COM VEH ❑ ® Ut CO
FIRST CONTACT 9 7 _, _6 •IfYes.See Sidebar C
ELGIN IL 60120 0 1 0 EG99218 IL 2025 REAR 0 N
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IL D 1 FM5K8D86GGB33034 State Farm ❑Y ®N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 2011281 sfp13 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)1(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
EA N 1 ® 11 4 05 129 l2025 10 15 0 PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
0 2 30 99 1 / 0 PM ❑Construction *
Z3 0 1!>I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2
o1 ® 11 4 ARREST NAME Erickson.Jay.A. 11-1402-A w1545-309 / ! El PM SLMT
o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility
30
t 2 0 ARREST NAME AM
7 1 r ❑❑PM 0 Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 - ❑AM Workers present? ❑Y 30
1545 VanEycke. Brier 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.
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- -, , ; ; , ; ( combination):or —I
INDICATE NORTH 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 L L----A--- 1 i. '-----.i.... J transporting employened to es Inthe course passengers5 or fewer thir emplod yment example:employeener X
} } }
transporter-usually a van type vehicle or passenger car):or 1:0
I- <.__-a-_-_-I , I- I- I- <--_-a__--- 1 , , , 4. Is used ordesi nated to trans rt between 9 and 15 passengers,including C} } for direct compensation(example:large van used for specificpurpose):or [he driver,
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L L----a____.: L L L ...._-.�_ ; l. i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires III
placarding(example:placards will be displayed on the vehicle). XI
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CARRIER NAME H & M Trucking Inc Z
ADDRESS 2522 ED BABE GOMEZ AVE O
CITY/STATE/ZIP Omaha I NA 168107 n
MOTOR CARR.ID El Interstate ❑ Intrastate
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❑ Not in Comm./Govt. ❑ Not in Comm./Other 0
:----Y----4 ; I- I- Y- ; ; , ; 0983 USDOT NO. 29 ILCC NO. m
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Source of above z
. IDOT PERMIT NO. WIDELOAD'7 0 Yes ®No =
TRAILER VIN 1 1 uyvs2537j3141101 co
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LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 0 ® 0 Z
TRAILER 2 ❑ 0 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 53f ft. 2 ft. w
Green Red
u 1 TOWED TOTAL VEHICLE LENGTH 63ft ft. NO.OF AXLES 3
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 1 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/TO.
DUE TO ® VEHICLE CONFIG. 3 CARGO BODY TYPE 9 LOAD TYPE 5