HomeMy WebLinkAbout2025-00041157 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
0110110000011
IIIIII 11 1111111111 111111 111111
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003870163
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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 El$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) El B Injury and/or Tow Due To Crash
0 AMENDED YR 2025I 2025-00041157 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 m
RT2OWB El In 05:43
® ❑ RELATED ❑Y ®N 06 27 2025 12,— ❑YES ®NO U1 -<
g PRIVATE mo /day/yr ®PM FLOW CONDITION m
q0 /MI N E COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 15
Ixl- O S W SHALES Pk Cook HIT&RUN ❑Y ® N WITH VEHICLES INVLD IN STOPPED U2 --I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
tg:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL ❑EWES ❑uuv ❑!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
0 5 /
yr 13-UNDER CARRIAGE 10. • 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ Ea U2 4 rn
M 2 4 ❑Y ® is-OTHER
SYSTEM❑UNK VEH. O AT CRASHD O 99-UNKNOWN 9 16•TOP 3 `Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s it a 4 COM VEH 0 Ea 1 0
" �- SOUTH ELGIN IL 60177 B 1 0 FIRST CONTACT 12 T_:1 __S *II Yes.See Sidebar U1
ZEZ15211 IL 2026 E
TELEPHONE
IL A 7 JA32U8FW8CU009337 PROGRESSIVE ❑Y ®N U2 1-
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 99 9 Same 991301058 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 2 ou
m Ei{ DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 New 0 KCV 0 Dv
+2 0 0 1 Hyundai Santa Fe 2013 00-NONE O1 12.._1 DUE TO CRASH 0 2 xl
o Yr 13-UNDER CARRIAGE 10/ 2 FIRE 0 ® U2 C
c
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 5 iI S 1,,_4 COM VEH D ® Ut CO
FIRST CONTACT 6 Y__{_O ._5 •(ryes,See Sidebar
= ELGIN IL 60120 B 1 0 CX23631 IL 2026 AR
IL D SXYZUDLA4DG100450 KEMPER ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
Elgin Fire 99 9 Same 12A0001574077 SAC E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Sherman 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 0 Y U2 Z
u 1 ® 11 1 61 ,71 /025 05 43 ®AM in a Work Zone? ®N DIRP co
1 r PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
0 2 ❑ 11 1 28 99 61 /71 /025 06 16
1 ®PM• ❑Construction >E
N 3 ❑ 11 1 El CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVE° TIME 7
z J ❑AM ❑Maintenance U2
— ® ElUtilit a, ARREST NAME FLOWERS. DERIK. L. 11-601 1551-000128 61 /71 /025 06 20 0 PM
o1 SLMT
U 11 1 CITATIONS ISSUED PENDING
o N 0 AM 45
SECTION CITATION NO. ROAD CLEARANCE TIME y
r 2 ❑ 1 1 1 ARREST NAME 61171 /025 06 23 ®PM ❑Unknown work zone type U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 45
1551-Dede.Joseph 401 81 / 21 /025 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
�____r____; T _ ) combination):ahoeight htratingmorethan10,000pounds{(example: -<
' 1. e le:truckortrucktrailer
INDICATE NORTH -11
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
Not Tb Scare I - } (example:shuttle or charter bus):or
x
L A I I l 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
(arwarm?r 1 - } } } transporting employees in the course of their employment(example:employee X
rter-
i_ <.___a__"_� I I I sop I.
4alsuosedordesllnatedtotrans vehicle
rtbetween9andr15r) C
ssen rs,includingthedrrver, y
I I I 1 ' } } for direct compensation(examp:large van used for specific purpose):or O
t l. I 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D
• I ,... - placarding(example:placards will be displayed on the vehicle). XI
-_ - a - - - , , Z CARRIER NAME Z
ADDRESS
I I I ll C
I CITY/STATE/ZIP 0
III
1 I t - MOTOR CARR.ID 0 Interstate 0 Intrastate
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
;_...Y._._; - USDOT NO. ILCC NO. m
XI
Source of above z
. MCS 0 Yes 0 No 0 Unknown Out of Service 0 Yes ❑No 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 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Silver Red
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Other/Unknown . 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