HomeMy WebLinkAbout2025-00041260 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 0110110000011 1*11E111111
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003670144
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 2025I 2025-00041260 VENT
ADDRESS NO. HIGHWAY or STREET NAME INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 "I
®CITY TOWNSHIP ❑ RELATED ❑Y ®N 06 28 2025 ®AM ❑YES ®NO U1
118 N GIFFORD ST Elgin 02:50
g PRIVATE mo !day!yr ❑PM FLOW CONDITION m
_ _
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW Cl)
❑ FT!MI N E S W Cook HIT ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 -I
&RUN
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 MAU 0 lacv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
FOR DAMAGEDAREA(S) FROM TOWED U1 Q
0 9
yr
13-UNDER CARRIAGE :to,/ !! 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 m
M I 2 5 n is-OTHER
El Y ®N
SYSTEM
❑UNK VEH. AT CRASH D 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN =
•
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s_iL 6 I, 4 COM VEH ❑ 0 2 0
~ ELGIN IL 60124 0 1 0 FIRST CONTACT 1 7 ; __5 *IIYes.See Sidebar U1
Z DX19768 IL 2025 REAR
TELEPHONE
IL D 1 C4PJ MAK2CW125389 Progressive ❑Y ®N U2 rM
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 966818851 1 1—
"6 HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 rg-
XI
0 DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 MAV 0 KCv 0 DV
yr 12 - C
Ti 13-UNDER CARRIAGE 10 1 2 FIRE ❑ ❑ U2 C
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 ❑ ❑ SPDR 0
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value U1 9 -
POINT OF s-.;, 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT Y�='+:=5 COM•1 sVEH See •Sidebar❑ 0
C
CO
F` pEA,- C
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O
❑Y ❑N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
BAC
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
RESP❑YD❑N NDER U1 =
(UNIT) (SEATI (008) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0
/ / U2 r
m
/
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 43 3 City of Elgin.City of Elgin ST LIGHT 118 N G I FFORD. 06,28 ,2025 02 50 ®❑pM 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 �
;, 2 0 1 3 150 DEXTER CT ELGIN IL 60120 20 28
! r ❑PM ❑Construction *
t
R 3 ❑ El CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME
❑AM ❑Maintenance U2
-a, ARREST NAME Beale.Christian. L. 11-601-Ax 1517000460 r ! El PM SLMT
o U 1 0 MI CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ElUtility
o N 0 AM 20
t 2 El ARREST NAME Beale.Christian. L. 11-709-A 1517000459 r r PM 0 Unknown work zone type U1
n 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y
1517-Le Cates. Brittany 301 07 , 15/2025 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. INDICATE NORTH combination):or .Z-1
A : BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
uerowstoti I _ ; Tr r (example:shuttle or charter bus):or
I- L.___A.._.� t 3. Isdesgnedto carry 15or fewer passengers and operated bya contract carrier I O
} } } transporting employees In the course of their employment(example:employee X
�� transporter-usually a van type vehicle or passenger car):or w
L 4. Is used or designated to transport between 9 and 15 passengers,includingC}-----}----; ( l - } } } g po the driver,
Nvcrb�ecwm for direct compensation(example:large van used for specific purpose):or O
L L--_-a-...J II l. i i L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
I placarding(example:placards will be displayed on the vehicle). ,Zmt
D
ICARRIER NAME Z
TO ' I - ADDRESS O
Not
C)
cwicoest atin , , , , , CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
I"--- ----4. - 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 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U_COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Black
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Adieu/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET
U_DUE ETOO T6 DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/
DUE T VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE