HomeMy WebLinkAbout2025-00034273 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II 111 I M UHI U I��1011111111111111l1 UU
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X4632-40651
u, 1 U21 2 4 8 U1 2 U2 1 U, 1 1_12 1 U, 1 U2 1 1 15 U1 1 U2 1 *P 0119*
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 ❑$501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
❑AMENDED YR 2025I 2025-00034273 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 mBENT ST Elgin02:13
® ❑ RELATED ®Y 0 N 05 29 2025 ❑AM ❑YES N NO U1 -<
_ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION m
FT!MI N E S W ST CHARLES ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 15 '
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
r4T
1 1 /
yr 13-UNDER CARRIAGE 10 I 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL)THERDISTRACTED 0 0 U2 0 NI m
M 2 4 SYTM❑Y NSNE❑UNK VEH. O AT CRASH 0 15-99-UNKNOWN 9 16•TOP 3 `Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s it 4 COM VEH 0 0 1 n
F. _FIRST CONTACT 12 7_ �S_,__5 *IIYes.See Sidebar U1 0
V Z Tinley Park I L 60477 0 1 0 1801842 B I L 2025 REAR
TELEPHONE
IN C 0 ZFBERFATXF6970096 Valley Insurance Group ❑Y IlN U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 99 9 Four Seasons Heating A99864403 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER
98 0
p; DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 iiuv 0 i v ❑Dv
!1 9 6 6 Honda CRV 2021 00-NONE till 12 .-y DUE O CRASH rg ® U2 2 73
C
o 13-UNDER CARRIAGE III
Ti
F 2 6 SYSTEM IN 0 ENGAGED 0 15-OTHER 9;1,6•TOPO3 * X
❑Y NJ DUNK VEH. AT CRASH 99-UNKNOWN POINT OF s_ O 0istracton Value 9
U1 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR � 5 1I 4 COM VEH ❑ N CO
FIRST CONTACT 3 7_i_, _5 •)ryes.See Sidebar
ST CHARLESREAR
Z IL 60174 6746 B 1 0 DL54235 IL 2026
C
D
IL D 0 2HKRW2H53MH616382 State Farm ID ❑N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire 99 9 Same 3381274-SFP-13 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)(TELEPHONE) (EMS) (HOSPITAL)
2 3 04 / M 2 6 B 1 0
m
/ / ##occs >
71
/ / U1 1 D
/ / 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 4 05/29 l2025 02 13 ®AM in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
v 2 0 2 28 05,29 ,2025 02 15 ®pM ❑Construction >F
R 3 0igi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
z J ❑AM ❑Maintenance U2
a ® 11 4 ARREST NAME Willis. Montell. D. 11-901-A S1542-000266 05,29/2025 02 20 Igi pM• • El Utility SLMT
I$[CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM
o t 2 El ARREST NAME Willis. Montell. D. 11-601 S1542-000267 05)29 ,2025 03 07 N PM 0 Unknown work zone type U1 30
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 30
1542-Chace. Ethan 401 275-Engelke 06 , 17,2025 09 00 ❑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
G‘I) 01. Has a weight rating more than 10,000 pouds(example:truck or truck/trailer -<
` ` -' -' r INDICATE NORTH combination):or .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i - To Scale I i - } ; (example:shuttle or charter bus):or
Not
L A
} } } transporting employees in the course of their employment(example:employee
rter-
y a van type vehicle or
L ...l. IC
42lsuosedordesllnatedtotransportbetween9a dr15passengers,includingthedriver,
} } 9 Po to
for direct compensation(example:large van used for specific purpose):or
L_ _ -. „ i. < i. L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
r .
°
A I � ` pWcartling(example:placards will be displayed on the vehicle). m
0
D
l' I- -:- 1 --111.\\ \ ll CARRIER NAME
ADDRESS 0
T.
C)
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
‘I. - --1 USDOT NO. ILCC NO. m
XI
Source of above z
. If Yes,Name on placard 0
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
0
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
White Silver
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Other/Unknown . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE