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HomeMy WebLinkAbout2025-00035277 ILLINOIS TRAFFIC CRASH REPORT sheet 1 Df 2 Sheets 01111101111 I0110110011 0 I DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003840621 u, 1 u21 3 4 1 u, 5 U2 1 u, 1 u2 1 u, 1 U2 1 3 10 u, 3 U2 1 *P 0119 INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 14 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash 0 AMENDED YR 202512025-00035277 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 6 m E HIGHLAND AVE EIin07:24 ® ❑ RELATED ®Y 0 N 06 02 2025 DAM ❑YES El NO U1 -< _ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION m FT!MI N E S W N GROVE AVE COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 10 fA ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EDUCE 0 buy 0 lacv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n FOR DAMAGEDAREA(S) FROPtf TOWED U1 Q Leonard.Chase.A. 0 9 / yr 13-UNDER CARRIAGE IE .10' !!. 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ga U2 2 m M 2 4 ❑Y ®SNEM❑UNK VEH. 0 AT CRASHD 0 99-UNKNOWN Ole•TOP 3 `Distraction Value ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s,_i� 6 �i COM VEH 0 j$J 1 0 H F. Piqua OH 45356 0 1 0 FIRST CONTACT 9 7 . -_5 *IIYes.SeeSidebar U1 Z q 212980TW IL 2024 iivui TELEPHONE OH Other 7 3C7WRNDL9PG545334 Amguard Insurance CO ❑Y ®N U2 19 . m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m T&A TOWING SERVICE K2GP530421 1 r "o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER r5 Refused RESPONDER 0 t 13 N DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑m v 0 NOV ❑Dv !2 0 0 6 Unknown Unknown 2016 00-NONE „ _.©!'O DUE TO CRASH ❑ 2 73 o 13-UNDER CARRIAGE i I, FIRE ❑ ® U2 Ti M 17 4 SYSTEM IN 0 ENGAGED 0 15-OTHER O9 16-TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istrac) n Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s i 6 i�-4 COM VEH ❑ ® U1 CO FIRST CONTACT 12 Y�� -=5 •(ryes.See Sidebar C ELGIN IL 60124 C 1 0 GC1996 IL 2025 I Si)0 Z IL D 0 JYARN47E2GA001300 none ❑Y ❑N RDEF EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same none BAc E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER ui = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((A.DDRESS)!(TELEPHONE) (EMS) (HOSPITAL) U2 m ##OCCS y 71 / / U1 1 D / / 1 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 06,02 l2025 07 24 ®pm in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 � o" 2 20 99 1 / 0 PM ❑Construction * 7 Z 3 ❑ I!!I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 o 1 ® 11 4 ARREST NAME Leonard.Chase.A. 11-708 482000534 / / El PM SLMT • I$!CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM• 0 Utility o r 2 El ARREST NAME Miller. Eric.C. 3-707 482000535 06/02 /2025 07 24 ®PM El Unknown work zone type U1 30 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 30 482-Flentye.Jeremy 1o1 07 ,01 /2025 01 30 ®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 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -< c ` -- -' I. INDICATE NORTH combination):or "'d ° BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } (example:shuttle or charter bus):or n N L A II 3. Is designed tol carry 15 or fewer passengers and operated by a contract carrier I O I. } } transporting employees In the course of their employment(example:employee X 1 i I . . . . transporter-usually a van type vehicle or passenger car):or w L i... . ..; - I. } 1.} 4. Is used or designated to transport between 9 and 15 passengers,including the driver. C e>Heikred7 we for direct compensation(example:large van used fors specific purose):or L L____a____.I - - - ,, ' - - - t _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires_. '�' placarding(example:placards will be displayed on the vehicle). ,Zmt D CARRIER NAME Z . . ... . 1 ri i _ ADDRESS O Not To Scale T. w C) CITY/STATE/ZIP MOTOR CARR.ID 0 Interstate 0 Intrastate 1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other ----'Y----1 - USDOT NO. ILCC NO. rn Source of above z . ❑ Yes 0 No 0 Unknown g D Did Carrier Safety Regulations(MCS)violation contribute to the crash? A ❑ Yes II ❑No 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 ❑Unknown Out of Service ❑Yes ❑No C Z Form Number 0 m Xl IDOT PERMIT NO. WIDELOAD? ❑Yes 0 No 2 TRAILER VIM 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. w White Black 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/TO: DUE TO ® Arties t Unknown VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE