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HomeMy WebLinkAbout2025-00040232 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 IIIIII 11 11111101111 111111111111 DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANY XO03&64750 u1 1 U2 1 1 1 U1 1 U2 U1 1 U2 U1 1 U2 3 4 U1 1 U2 *P 0119 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 ❑$501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00040232 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n S MCLEAN BLVD Elgin 08:34 ® ❑ RELATED ❑Y ®N 06 23 2025 DAM El YES ®NO U1 -< _ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m FT!MI N E S W SPARTAN DR COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW Cl) ❑ Kane HIT&RUN ❑V ® 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 0 PEOAL 0 EDUCE 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 0 0 7 / yr 13-UNDER CARRIAGE © I!. 2 FIRE 0 ® C STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED 0 0 U2 m M 2 4 SY15-OTHER ❑Y ❑SNE®UNK VEH. 9 ATCRASD IN ENGAGE9 99-UNKNOWN 016 3 `Distraction Value 9 ALGN 2 1• CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR • POINT OF $,_;—iL s �i,4 COM VEH El El 1 O I= FIRST CONTACT 11 7 ;_-5 *If Yes.See Sidebar U, Z South Milwaukee WI 53172 0 1 0 AHM6439 WI 2026 "a TELEPHONE WI D 1 HGCV1 F36LA072875 American Family ❑Y Il N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Demiri.Anife 985849891029FPPAWI 1 r o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 2 ou ❑ DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 yr 12 _ C1 o 13-UNDER CARRIAGE 10( c. 2 FIRE ❑ ❑ U2 C c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP 3 0 ❑ SPDR 0 0 Y ❑N 0 UNK VEH. AT CRASH 99-UNKNOWN *Oistreci n Value U1 0 - POINT OF s-.;, 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT TA—d:=5 COM•I sVEH See •Sidebar❑ ❑ C CO F` ---,- 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 X BAC HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < RESPNDER❑YD❑N U1 = (UNIT) (SEATI (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0 / / U2 r m Pj / / U1 1 D 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 15 1 City of Elgin Deer 06,23 /2025 08 34 ®AM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 v t 2 0 150 DEXTER CT ELGIN IL 60120 21 21 ! / ❑PM ❑Construction * Z3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 -a, ARREST NAME / / ID PM ' o U 1 0 ❑CITATIONS ISSUED ❑PENDING UtilitySLMT o N El AM SECTION CITATION NO. ROAD CLEARANCE TIME 0 t 2 ElARREST NAME 06/23 /2025 09 16 ®PM El, Unknown work zone type U1 35 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME Y 2 3 0 - ❑AM Workers present? ❑ 1560-Jones. Bennett 702 / ❑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 l ADDITIONAL UNITS FORMS. r ----r•---, , Mclean?Blvd. A CMV is defined as any motor vehicle used to transport passengers or property and: 3> N 01. Has a weight rating more than 10,000 pounds(example:truck or truck trailer ` ` '' -4. r INDICATE NORTH combination):or —11 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver _ } (example:shuttle or charter bus):or X . A I } 3. Is designed to carry 15 or fewer passengers and operated a contract carrier O } } transporting employees In the course of their employment(example:employee X transporter-usually a van type vehicle or passenger car):or CO L I 4. Is used or designated to transport between 9 and 15 passengers,including N }-----}----; I - } } } g po passen rs,includi the dryer, for direct compensation(example:large van used for specific purpose):or O Not To Scale I - } t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires M pWcartlin9(example:placards will be displayed on the vehicle). J I` -- Untt#2 CARRIER NAME Spartan?Dr. z — — — — — _ ADDRESS 0 T. 1 C) , , , , CITY/STATE/ZIP MOTOR CARR.ID ❑ Interstate ❑ Intrastate g I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other �"--------1 - USDOT NO. ILCC NO. rn 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. 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? ❑ Yes II No ElUnknown A 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 v TRAILER WIDTH(S) 0-96" 97-102" >102' m TRAILER 1 ❑ ❑ 0 Z ill TRAILER 2 ❑ 0 0 o u 1 COLOR U_COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Silver 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/T6 DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE