HomeMy WebLinkAbout2025-00036457 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Df 2 Sheets 01111101111 0110110000100 1110
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0038845897
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
0 AMENDED YR 202512025-00036457 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m
464 WI LCOX AVE El 11:24
® ❑ RELATED ❑Y ®N 06 07 2025 ❑AM ❑YES El NO U1 -<
_ g PRIVATE mo !day!yr ®PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ FT/MI N E S W Kane HIT ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 —I
&RUN
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER I] PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
! !
FOR DAMAGEDAREA(S) FRObir�TOWED U1 Q
NAME(LAST,FIRST,M) Unknown.O. mo yr Ford F350 2019 00-NONE 11_' QZ ,a:/DUE TO CRASH ® ❑
13-UNDER CARRIAGE NI
10 : 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED U2
9 9 SYSTEM IN 9 ENGAGED 9 15-OTHER 9 16-TOP 3 0
' _
❑Y ❑N CDUNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 9 ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6,_i� 6 �i COM VEH 0 j$J 1 0
~ 0 9 0 FIRST CONTACT 1 7 . -_5 *lives.See Sidebar Ut
ksui
Z 4189908B IL 2026
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 11/
1 FT8W3BT3KEE19864 State Farm ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR
Pu Us. Baltazar 3644781-SFP-13 2 m
`o HOSPITAL(TAKEN TO) INCIDENT IF`Y' OWNER STREET.CITY,STATE,ZIP PHONE NUMBER
RESPONDER
99 0
0 DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0!My 0 Ncv 0 DV
yr 13-UNDER CARRIAGE 10,i 12 •
2 FIRE ❑ ® U2 C
Ti SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 0 ® SPDR n
0 Y ❑N 0 UNK VEH. AT CRASH 99-UNKNOWN *0istraci n Value U1 9 -
POINT OF 6 ) 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6 [}_. COM VEH ❑ ® CO
F,,, FIRST CONTACT 1 7 _ _5 C.
If Yes.See Sidebar
EE40117 IL 2025 I 0 Si)
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
JTHCK262992029461 First Chicago Insurance 0 Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Pu Us. Baltazar I LS-11 38649-00 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 18 9 06,07 l2025 11 24 ®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 28 99
N 3 0 CITATIONS ISSUED 0 PENDING + ! ❑PM• ❑Construction >E
SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM 0 Maintenance U2
-a, ARREST NAME / / ❑PM '
o u El 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT
30
r 2 ARREST NAME AM
7 El r ❑❑PM 0 Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 1529-Audi red.Jonathan 701 331-Ziegler , ! D PM Workers present? ®N U2 30
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 ist defined as any motor vehicle used to transport passengers or property and: Z
-<
0 . Has a weight rating more than 10,000 pounds(example:truck or truck trailer
` ` -'- -' r INDICATE NORTH combination):or .Z�1
Wilcox?Ave. BY ARROW 12 Is used or designed to transport more than 15 passengers including the driver C
_ } (example:shuttle or charter bus):or 0
L A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier O
} } } transporting employees In the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
L }-----}----I. - • } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver. w
464.Wilcox?Ave. for direct compensation(example:large van used for specific purpose):or O
__ __ � I 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle).
CARRIER NAME
_ __ 1 ADDRESS 'O
0
XI
Not To Scale CITY/STATE/ZIP
MOTOR CARR.ID ❑ Interstate ❑ Intrastate
I I T ❑ Not in Comm.lGaA. Not in Comm.lOther
‘I. - --4. USDOT NO. ILCC NO. m
XI
Source of above z
. 0 Yes II No ❑ Unknown A
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
ill
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 3 TOWED BY/TO.
_Adieu/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 DUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE