HomeMy WebLinkAbout2025-00039136 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY X003862O56
u, 1 U2 1 1 1 U1 1 U2 U, 1 1_12 U, 1 U2 1 5 U1 15 U2 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY ❑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 8
VEHICLE/PROPERTY ®OVER$1,500
El NOT ON SCENE(DESK REPORT)
0 AMENDED ® 6 Injury and for Tow Due To Crash YR 202512025-00039136 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 13 �I
900 N STATE ST Elgin01:51
® ❑ RELATED ❑Y ®N 06 19 2025 DAM ❑YES ®NO U1
_ PRIVATE mo /day/yr ®PM FLOW CONDITION m
COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR 0 SLOW 0)
❑ FT!MI N E S W Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
FOR DAMAGEDAREA(S) FRONT TOWED U1 Q
EN
Gallagher. Ultan. P. 0 8 /
yr 13-UNDER CARRIAGE I-. 2 FIRE ElSTREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 NI E
]$I U2 rn
M 5 Q ❑Y SYSTEM IN ENGAGED 15-OTHER 9 6 70P 3 _
❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF Tall,.4 COM VEH I1 ❑ 6 OLI
c Z E LG I N I L 60120 0 1 I L 2025 FIRST CONTACT 11 7_;LQ FicAii-_5 *If Yes.See Sidebar U1
TELEPHONE
IL D 4XARSU998K8892231 Fleet ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
a
City of Elgin. Elgin Fleet 5
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER r
2
0 DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0
yr 12 _ C1
o 13-UNDER CARRIAGE 10 I c. 2 FIRE ❑ ❑ U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 ❑ ❑ SPDR 0
D Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `0istraellon Value U1 0 -
POINT OF s-.;, 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 7A—'1:=5 COM•I sVEH See •Sidebar❑ 0
C
CO
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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 10 =
BAC
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
RESP❑YDNDER❑N U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0
1 3 01 / M 5 3 B 1 0
I71
/ / #OCCS >
/ / UI 2 D
/ / 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 2 5 06!19 l2025 01 55 ®pm in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 ❑ 18 28
1 ! ! ❑PM. ❑Construction *
Z3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2
-a, ARREST NAME / / ❑PM '
o u 0 CITATIONS ISSUED ❑PENDING •SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utilit 20
y
SLMT
t 2 ARREST NAME AM
! 1 ❑❑pM El Unknown work zone type U1
El
7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y
2 3 El ❑AM Workers present? ❑
275 Engelke. Robert 500 226-Roscher ! / ❑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 truck trailer -<
` ` --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 i_ - } (example:shuttle or charter bus):or 0
Not To Scale I 3. Is designed to carry15 or fewer
L L A tg 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 CO
L L.___a__. 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or O
unit
® m�sonet Covet. 4. t 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 —I
i ADDRESS 0
w
CITY/STATE/ZIP I n
MOTOR CARR.ID 0 Interstate ❑ Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
�I. ------1 - USDOT NO. ILCC NO. rn
XI
Source of above z
. xi
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
to
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_COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Black
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U_TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO.DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE