HomeMy WebLinkAbout2025-00040810 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111 011011000 01111111111111111
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑5501-51.500 ®ON SCENE 2
VEHICLE/PROPERTY ElOVER 51,500 ❑NOT ON SCENE(DESK REPORT) El B Injury and/or Tow Due To Crash
0 AMENDED YR 2025I 2025-0004081 O VEHT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 16
® ❑ RELATED ®Y 0 N 06 26 2025 ®AM ❑YES ®NO U1 -<
NATIONAL ST Elgin08:16
_ g PRIVATE mo /day/yr ID PM FLOW CONDITION m
FT!MI N E S W TIMES SQ COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 2 fA
❑ Kane HIT&RUN ❑V ® N WITH VEHICLESOT,
INVLD ❑ STOPPED U2 —I
Igl AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS O
0 DRIVER ❑ PARKED ❑DRIVERLESS Ig) PED ❑PEON. ❑EWES ❑uuv ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 n
FOR DAMAGED AREA(S) FROM TOWED U1 I�
NAME(LAST,FIRST.M) Kroll. Michael. D. m0 D /4 T /1 9 yr 8 Unknown 2025 00-NONE 11 O i-1 DUE TO CRASH ❑
EN
13-UNDER CARRIAGE 10 i 2 FIRE 0 NI E
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 3 <<T1
M 1 3 El ®SNE❑UNK VEH. O ATCRASHIND O 99-UNKNOWN 9 16•TOP 3 `Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s_iL 6 4 COM VEH 0 j$J 1 0
F.
FIRST CONTACT 12 7
ELGIN I L 60120 A 1 0 _:REAR
_5 *II Yes.See Sidebar U1 2
2 Z
TELEPHONE
IL D 0 NIA ❑Y ❑N U2 I—
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
1 49 6 Same NIA 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER XI
Provena St.Joseph ❑Y El 2 0
p; DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑row 0 NOV ❑Dv
/1 9 6 9 Ford F450 1999 00-NONE 1("j 12--_1 DUE TO CRASH 0 2 x
o - 13-UNDER CARRIAGE 'I FIRE ❑ ® U2
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istraellon Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-iI 6 ij:, 4 COM VEH ❑ ® U1 CO
FIRST CONTACT 2 Y _, _5 •(ryes,See Sidebar
H ELGINREAR C
M IL 60123 0 1 0 219AC583 IL 2025
IL D 0 3FDXF46F6XMA38464 State Farm ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Montoya. Neli 0001568-SFX-13 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/{ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 12 1 Kroll. Michael. D. Black Scooter 06,26 /2025 08 16 ®❑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 C)
v 1 2 0 669 WRIGHT AVE ELGIN IL 60120 2 99 06,26 ,2025 08 16 ❑PM 0 Construction 5 >F
R 0 0 CITATIONS ISSUED El PENDING SECTION CITATION NO. EMS ARRIVED TIME
3 ®AM ❑Maintenance U2
-a, ARREST NAME Kroll. Michael. D. 11-1003 1527000327 06/26/2025 08 19 0 PM SLMT
® 12 1 0 Utility
SECTION CITATION NO. ROAD CLEARANCE TIME
o N 1 Ely CITATIONS ISSUED PENDING
AM 30
T 2 El ARREST NAME 06/26 /2025 08 19 MPM ElUnknown work zone type U1
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 0 AM Workers present? ❑Y 30
1527-Juarez.Jorge 401 237-Copland 07 , 15/2025 01 30 ®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 -<
c ` --I -' r INDICATE NORTH combination):or .Z-1
(I) BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
- } (example:shuttle or charter bus):or
X
I- L.___A.._.� I I I . 3. Isdesgnedto carry 15or fewer passengers and operated bya contract carrier 0
} } transportingemployees in the course of their employment(example:employee X
I I I transportr-usually a van type vehicle or passenger car): r
L L.___a.._..I I _ 4. Is used ordesinatedtotrans rtbetween9and15passengers,includingthedriver. C
3 r I IQI u t t } • for direct compensation(example:large van used for speific purose):or
a t i i • 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
C <, placarding(example:placards will be displayed on the vehicle). XI
-r>— �. ---- - -- —I
'slt'I'tlt" — _ CARRIER NAME Z
7I I I ADDRESS 01 I I I !
-No I If_.—_ I I I 0
I I I CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate ❑ Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
; _Y_ _ 4. USDOT NO. ILCC NO. rn
XI
Source of above z
IDOT PERMIT NO. WIDELOAD-; ❑Yes 0 No =
TRAILER VIN 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Black White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE