HomeMy WebLinkAbout2025-00037195 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 0110110 0 I0H 1110111I 0
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INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ®5501-$1,500 ®ON SCENE 1
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and f or Tow Due To Crash YR 202512025-00037195 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m1285 N LYLE AVE El In10:11
® ❑ RELATED ❑Y ®N 06 11 2025 ®AM ❑YES El NO U1
g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
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COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ FT!MI N E S W Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I
O AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER O PARKED 0 DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 NW 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 01 n
FOR DAMAGEDAREA(S) FROM TOWED U1
NAME(LAST,FIRST,M) mo yr O
Unknown.0. / ! T
Unknown Unknown 00-NONE 0O 0 DUE TO CRASH 0 EN E
13-UNDER CARRIAGE I FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O DISTRACTED 0 0 O1 m
U2
SYSTEM IN ENGAGED 15-OTHER 916.70P 3
9 9 ❑Y ❑N [DUNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN =
s 4'a— CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF ,Ii_S Ii,_ 1
I— 0 9 FIRST CONTACT 7_: COM VEH 0 Ea
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2 Z ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 11/
o UNK. 9 Unknown ❑Y ❑N U2 m
.5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same Unknown 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ❑ N 99 0
0 DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMV 0 NCv 0 DV
!2 0 0 6 Nissan Maxima 2016 00-NONE 'o,I t2 c,�2 DUE O CRASH 0 ® U2 2 73
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❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value g g
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FIRST CONTACT 7 O7 �_ ==Q�:._5 •If Yes.See Sidebar
Lebanon TN 37087 0 1 0 573BNXS TN 2025 REAR 0 Si)
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TN D 0 1 N4AA6AP1 GC439559 Progressive ❑V ®N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Mosley. Kerri 983427008 BAC
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HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) {DM (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1{ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
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EV MOST EVNT DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 18 9 co
06,11 ,2025 10 11 ®❑PM AM in a Work Zone? ®N DIRP D
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 C)
2 ❑ 06 28
N 3 ❑ 0 CITATIONS ISSUED 0 PENDING + ! 0 PM• El Construction
SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
—a, N ARREST NAME / / _ ❑PM
1 ® 11 1 0 CITATIONS ISSUED ❑PENDING • UtilitySLMT
o SECTION CITATION NO. ROAD CLEARANCE TIME 0
AM 25
t 2 0 ARREST NAME 06 r 1 1 12025 10 11 MPM ElUnknown work zone type U1
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ ❑AM Workers present? ❑Y 25
1543-Sturgeon. Kyle 500 275-Engelke , / ❑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
�___--I--___; I _ 1. Hasa weight
ign):ht rating more than 10,000 pounds(example:truck or truck trailer -<xamp :
il
INDICATE NORTH p3
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
?gt 12eevn9141.9.9 - (example:shuttle or charter bus):or 0
I- ------I-•---I - transportingdesigned
tploaeeslin the course o their m operated contractcarrier
3. Is and pe ated by a rie I O
ii--i } r } - y a van vehicle or employment(example:employee w
transporterusually type passenger car):or �
m C
-- -- - I. } } 1 •4. Is used or designated to transport between 9 and 15 passengers,including the driver. N
for direct compensation(example:large van used for specific purpose):or O
L �____a____� � l. I• I _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
IIII
toftrarrin
I placarding(example:placards will be displayed on the vehicle). XI
I
- CARRIER NAME Z
ADDRESS 'O
D
1 I
NOt TO Scale CITY/STATE/ZIP o
I MOTOR CARR.ID 0 Interstate 0 Intrastate
I r ❑ Not in Comm./Govt. 0 Not in Comm./Other
-----------1 - USDOT NO. ILCC NO. rn
XI
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
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LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Blue
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 9 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE