HomeMy WebLinkAbout2025-00038202 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
I011011000011
1011100
I
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00366558
u, 1 U21 2 4 1 U199 U2 1 U, 1 u2 1 U,99 U2 1 1 15 U, 1 U2 1 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER 31,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
0 AMENDED YR 2025I 2025-00038202 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 10 mCOOKANE AVE Elgin08:36
0 ❑ RELATED ®Y ❑N 06 15 2025 ❑AM ❑YES I NO U1 -<
_ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION m
FT!MI N E S W MAY ST COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 15 u)
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!Cy 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
FOR DAMAGED AREA(S) FRO T TOWED U1 Q
Merwin. Kevin.T. 1 2 /
yr 13-UNDER CARRIAGE 10 !!. 2 FIRE 0 N
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL O4-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
M 5 4 15-OTHER
❑Y ®N
SYSTEM
❑UNK VEH. 0 AT CRASHD 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8_iL S ii,4 COM VEH 0 j$J 1 0
~ ELGIN I L 60120 K 2 9 FIRST CONTACT 1 7_; __5 *II Yes.See Sidebar U1
Z NONE ' E
TELEPHONE
IL D 0 JS1GN7CA442105867 None ❑Y ❑N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 99 9 Bibriescas, Edgar None 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 ou
m x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0!My 0 Ncv 0 Dv
yr 10 j t2 ( z FIRE ❑ N U2 C
o 13-UNDER CARRIAGE
c
M 2 8 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOPO3 * X
❑Y i N ElUNK VEH. AT CRASH 99-UNKNOWN Distraction Value 9 3
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-.1. 6 j( 4 COM VEH ❑ N U1 CO
FIRST CONTACT 2 Y'_, _5 •• •IfYes,See SidebarC
H ELGIN IL 60123 0 1 0 EX18130 IL 2025 I 0
M
IL D 0 1 G N EVH KW8LJ 183645 Direct Auto ❑Y N N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
Elgin Fire 99 9 Same PAI L00121690 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER
U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME))(ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
2 12 10 /
4 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 06,15 l2025 08 36 ®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 C)
2 ❑ 28 99 06,20 ,2025 08 36 PM
® • 0 Construction >F
en
Z 3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM 0 Maintenance U2
- N a ARREST NAME 06,20/2025 08 50 ®pM '
,
1 ® 11 1 ❑CITATIONS ISSUED ❑PENDING Utilit SLMT
o 0 y
SECTION CITATION NO. ROAD CLEARANCE TIME AM U1 30
t 2 El ARREST NAME 06(15 l2025 00 00 In PM 0 Unknown work zone type
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ 1535-Solis, Laura 401 391-Jacobucci , / ❑❑PM Workers present? ®N U2 30
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
r iCO f combing rg ore than pound { a p .truck or truckrtrarler
1. Has a weight ratio m 10 000 5 ex m le' -<
INDICATE NORTHIlon)oBY ARROW2 Is used or designed to transport more than 15 passengers including the driverC
V (example:shuttle or charter bus):or n
r 3. Is designed to car 15 or fewer ssen ers and o rated a contract carrier O
- } } } transporting employees In the course of their employment(example:employee X
3 1 um. 1 transporter-usually a van type vehicle or passenger car):or w
L •-----}----; ��-- - • } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver, N
1 ! ! for direct compensation(example:large van used for specific purpose):or O
L i.____a____.: UV _ t i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). ;p
-1
-11
CARRIER NAME Z
Ir ADDRESS 'O
V)
CITY/STATE/ZIPC)
MOTOR CARR.ID 0 Interstate ❑ Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
--- --1 USDOT NO. ILCC NO. m
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
co
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
White Black
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO.
Redmons/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE