HomeMy WebLinkAbout2025-00040201 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 0110110011 0111101011100
DRAC TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY XO03&64/49
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INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and for Tow Due To Crash YR 2025I 2025-00040201 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 m® ❑ RELATED PRIVATE ❑Y ®N 06 23 2025 ❑AM ❑YES ®NO U1
BIG TIMBER RD Elgin mo /day/yr 05:31 ®PM FLOW CONDITION M
•
02040!MI NOS W North MCLEAN Blvd COUNTY PROPERTY ❑Y ® N DOORING El #OF MOTOR ❑SLOW 1 Cl)
Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ® STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
(i DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑NUV ❑ncv ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 8
0 3 /
yr �° �:/
13-UNDER CARRIAGE 10 1 2 FIRE 0 ® <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 rn
F 2 4 El ❑SNEM CD UNK VEH. 9
r ATCRASHD 9 99-UNKNOWN 15-OTHER 9 16•TOP 3 `Distraction Value 9 ALGN =
CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, it a •
4 COM VEH 0 j$J 1 0
~ ELG GIN I L 60123 0 1 0 FIRST CONTACT 12 7_;1 _5 *II Yes.See Sidebar U1
ZREVRAD3 IL 2026 WAR ' E
TELEPHONE
IL D KNDJ33AU3N7826399 AUTO-OWNERS INSURANCE ❑Y ®N U2 Rr-
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 HERMANS.SCOTT.C. 55-146-418-01 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 73
m g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑iiuv 0 Ncv 0 DV CIRCLE NUMBER(S) U1
'1 9 9 2 Hyundai Elantra 2014 oo-NONE ,�_"j 12..-_, DUE TO CRASH ❑ El 2 x
0Yr 13-UNDER CARRIAGE 10'( 2 FIRE El ® U2 C
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F 2 4 SYSTEM ENGAGED 19-OTHER 9,16•TOP 3 9 0
❑Y ❑N El UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value
POINT OF s i 4 COM VEH 0 ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6
FIRST CONTACT 6 O7 ,�=Q.OS •If Yes,See Sidebar C
WEST DUNDEE IL 60118 0 1 0 EF85563 IL 2025aR0 fp
IL D SNPDH4AE2EH524918 STATEFARM ❑Y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Same 3078222-SFP-13 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER
u1 =
(UNIT) (SEAT) (DOE)) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)/)TELEPHONE) (EMS) (HOSPITAL)
2 4 03 /
2 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 1 61 ,31 /025 05 30 ®pm in a Work Zone? ®N DIRP co
1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
o"
2 0 10 28 / / ❑FM ❑Construction *
4
R 3 0 $I CITATIONS ISSUED 3 PENDING SECTION CITATION NO. EMS ARRIVED TIME
❑AM 0 Maintenance U2
-a, ARREST NAME HERMANS. MADISON.C. 11-601-Ax 1560000008 / / El PM SLMT
o N ® 11 1 0 -CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
45
t 2 ARREST NAME AM
7 El / 1 ❑❑PM El Unknown work zone type U1
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 45
1560-Jones. Bennett 500 81 / 12 /25 09 00 ❑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-- --; Unit Big?Timber?Rd. combination):or —I
c INDICATE NORTH p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
(example:shuttle or charter bus):or
3. Is designed to carry15 or fewer passengers and operated a contract carrier O
}} } transporting employee in the course of their employment(example:employee
Unit#1 transporter-usually a van type vehicle or passenger car):or CO
L L.___a__._� 4. Is used ordesi natedtotrans rtbetween9and15passengers,includingthedriver. C
Not To Scale i I } } } •
for direct compensation(example:large van used for speific purose):or 0
L L--_-a-___i I - t i. i I 5. Is any vehicle used to transport an hazardous material(HAZMAT)that requires
I ` placarding(example:placards will be displayed on the vehicle). m
0
_ — —
N?Mdaan?Blvd. CARRIER NAME Z
._ ADDRESS 0
w
C)
— — — — CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
0Ir
I . I ❑ Not in Comm./Govt. Not in Comm./Other 1 I USDOT NO. ILCC NO. m
XI
Source of above z
. If Yes,Name on placard 0
4 digit UN NO. 1 digit Hazard class No. XI
XI
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 No 0 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
ill
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Black White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE