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HomeMy WebLinkAbout2025-00036168 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I0110110011 110011111II0011110 DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X00384,452 u, 1 U2 1 1 1 U1 2 U2 U, 1 1_12 u1 3 U2 1 6 U1 1 U2 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 3 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash El AMENDED YR 202512025-00036168 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ® ❑ RELATED PRIVATE ❑Y ®N 06 06 2025 DAM ❑YES ®NO U1 -< SOUTH ST Elgin mo /day/yr 04:57 ®PM FLOW CONDITION m ®70�F !MI N E S © South RANDALL Rd COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW Cl) Kane HIT&RUN ❑Y ® N WITH VEHICLESOT, INVLD ❑ STOPPED U2 -I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EouES 0 uuv 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 1 () FOR DAMAGEDAREA(S) FROPtf TOWED U1 0 WYMAN.ALEXANDER.A. 1 0 / yrIE 13-UNDER CARRIAGE 10.I !�. 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 m M 2 SY is-OTHER 4 ❑Y ®SNE❑UNK VEH. O AT CRASM IN H O 99-UNKNOWN 9 t6•TOP 3 `Distraction Value 9 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s it 6 1, COM VEH 0 Ea 1 C) 4 m ~ ELGIN IL 60124 0 1 0 FIRST CONTACT 11 l .; --5 *II Yes.See Sidebar U1 0 Z EE87658 IL 2025 REAR TELEPHONE IL D 1 C4SDJCT5MC786620 STATE FARM ❑Y ®N U2 m B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same 1711067SFP13 1 r o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ® N 2 0 ❑ DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 NMy 0 KCV 0 DV yr 12 _ C1 o 13-UNDER CARRIAGE 10.i t, 2 FIRE 0 0 U2 C c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 ❑ 0 SPDR n ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistrac) n Value U1 2 - POINT OF s-.;, 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT Y.='+:-6 C•IO e1sVEH See •Sidebar❑ 0 C CO F` REAR` co M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O ❑Y ❑N RDEF73 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = BAC HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < RESP❑YD❑N NDER U1 = (UNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) n / / U2 r m Pj / 0 EV MOST EVNT LOD DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 43 1 06/06 l2025 04 57 ®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 Oi 2 0 28 10 ! ! ❑PM• ❑Construction * R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 -a, ARREST NAME WYMAN,ALEXANDER.A. 11-601 1554000077 ! ! El PM o u 1 ❑ CITATIONS ISSUED PENDING UtilitySLMT o N SECTION CITATION NO. ROAD CLEARANCE TIME ❑ t 2 0 ARREST NAME 06!06 /2025 06 00 0 PM El Unknown work zone type U1 3O n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 3 ID ❑qM Workers present? ❑Y 1554-Wagener.Vincent 801 06 ,24 12025 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 -< ` ` --I -' r INDICATE NORTH combination):or .Z-1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C - } (example:shuttle or charter bus):or X L A }Q 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O } } transporting employees in the course of their employment(example:employee X transporter-usually a van type vehicle or passenger car):or w memad. I C L L.___a__ 4. Is used ordesi natedtotrans transport passengers,including y} } } g po passen rs,includi the driver, mms • • for direct compensation(example:large van used for specific purpose):or O L L____a____. t 5 Is an vehicle used to transport any hazardous material(HAZMAT)that requires -U l placarding(example:placards will be displayed on the vehicle). XI i r� —— CARRIER NAME Z �� �_\ ADDRESS D w C) CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate ❑ Intrastate I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other ‘I. - --1 - USDOT NO. ILCC NO. m 73 Source of above z . Were HAZMAT placards on vehicle? 0 Yes 0 No = If Yes,Name on placard O 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_COLOR TRAILER LENGTH(S)1 ft. 2 ft. w Gray u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. _Other/Owners Residence . SELECT CODES FROM THE BACK OF CRASH BOOKLET U_TOWEDDUET DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO: DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE