HomeMy WebLinkAbout2025-00037128 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003 .54076
u, 9 U21 1 1 1 U110 U2 1 U199 1_12 1 u,99 U2 1 1 9 u, 2 u222 *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 ®5501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00037128 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I
® ❑ RELATED 0 Y ®N 06 11 2025 ®AM ❑YES IX]PRIVATE NO U1
KI M BALL ST Elgin mo /day/yr 08:24 ❑PM FLOW CONDITION Ill
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®2040!MI 10 E S W North State St COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 5 0)
Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ® FREE FLOW # LNS 0
(g DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 04 n
FOR DAMAGEDAREA(S) FRONT TOWED U1 O
NAME(LAST,FIRST,M) Unknown.0. mo / / yr Honda Element 2010 00-NONE 11_' QI7.1 DUE TOCRASH 0 13-UNDER CARRIAGE ) �:/ FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 O 0 04 m DISTRACTEDU2
9 9 SYSTEM IN O ENGAGED 0 15-OTHER 9 16-TOP 3 ' _
❑Y ®N ❑UNK VEH. .ATCRASH 99-UNKNOWN `Distraction Value 9 ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6_iL 4 COM VEH 0 j$J 1 0
I— 0 9 FIRST CONTACT 99 7_; __5 *IIYes.SeeSidebar U1
z FG52117 IL 2026 REAR
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 11/
UNK. Other 9 5J6YH2H35AL007140 Unknown ®Y ❑N U2 I'
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 MCCLAIN. MARIE.A. Unknown 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
99 0
5, 0 DRIVER N. PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 NMv 0 NOV 0 DV
/1 9 6 5 El Dorado MfgEZ!rtder 2007 00-NONE 1("j 12�"_, DUE TO CRASH ❑ ! l 29 x
oy yr 13-UNDER CARRIAGE 10'1 c. 2 FIRE ❑ ® U2 C
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistractlon value 9 g
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N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 4 COM VEH ® 0 Ut W
FIRST CONTACT 7 k 6 -5 *If Yes.See Sidebar
Lake in The Hills IL 60156 0 1 0 M172659 IL 2000 REAR 0
IL B 7 1 N9MNAC657C084091 Self Insured ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER I X
99 9 PACE SUBURBAN BUS DI Self Insured BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE:ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (WI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)(TELEPHONE) (EMS) (HOSPITAL)
2 7 05 /
DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 18 9 06/11 /2025 08 24 ®p PM AM in a Work Zone? ®N DIRP D
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1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 1 C)
T
v 1 2 0 04 2 / / ❑PM ❑Construction
Z 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
-a, ARREST NAME / / ❑PM '
1 ® 1 1 1 0CITATIONS ISSUED ❑PENDING UtilitySLMT
NSECTION CITATION NO. ROAD CLEARANCE TIME
o - ❑
AM U1 30
t 2 0 ARREST NAME 06/11 /2025 09 09 M PM ❑Unknown work zone type
T
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
❑Y 30
1543-Sturgeon. Kyle 600 - / / ❑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••--, , I I A CMV is defined as any motor vehicle used to transport passengers or property and: ZI
�____r____; III11.1
Icombination):org ore than pound { a p .truck ortruckrtrarler
1. Hasa ratio m 10000 5 ex m le' -
NDICATE NORTHp0
BY ARROW 2 Is used or desi ned to tran ort more than 15 C
g sp passengers including the driver C} r rr (example:shuttle or charter bus):or 0
3. Is desgned to carry 15 or fewer passengers and operated by a contract carrier I O
I - } } } transport) em to ees In the course of their em
ng p y pbyment(example:employee X
IIy transporter-usually a van type vehicle or passenger car):or GB
I. } 1. •4. Is used or designated to transport between 9 and 15 passengers,including the driver, w
z I for direct compensation(example:large van used for specific purpose):or O
II y I Klmball?St } t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires -0
J ti placarding(example:placards will be displayed on the vehicle). XI
- L L - CARRIER NAME Z
ADDRESS 'n
_ U)
Not To Scale I CITY/STATE/ZIP I 0
g
I I I ,. / _ MOTOR CARR.ID 0 Interstate El Intrastate
r I ~ ❑ Not in Comm./Govt. ❑ Not in Comm./Other 00
--- --4. I I I - USDOT NO. ILCC NO. C
m
XI
Source of above z
. 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 ® 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 ®No 2
TRAILER VIN 1 m
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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
Silver 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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE