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HomeMy WebLinkAbout2025-00041422 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets _ 01111101111 011011000011111 fl 1 111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00387OC84 u, 9 U2 1 1 1 U, 2 U2 U,99 1_12 U,99 U2 1 1 9 U1 17 U221 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away Elgin Police Department ONE PERSON'S 1215501-$1.500 ❑ON SCENE 7 VEHICLE/PROPERTY ❑OVER$1,500 ®NOT ON SCENE(DESK REPORT) ❑AMENDED ❑ B Injury and/or Tow Due To Crash YR 2025512025-00041422 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m 160 SYMPHONY WAY Elgin06:45 ® ❑ RELATED ❑Y ®N 06 28 2025 ❑AM ❑YES ®NO U1 _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR IR SLOW 6 (n ❑ FT/MI N E S W Kane 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 g DRIVER I] PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EDUCE 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 FOR DAMAGEDAREA(S) FRONT TOWED U1 0 Unknown.O. / ! Toyota Tacoma 2017 00-NONE ©, 12 , DUE TO CRASH ❑ EN NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 10.I !�. 2 FIRE 0 IE < STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 m F 9 9 ❑Y SYSTEM IN ENGAGED 15-OTHER 9 16•TOP 3 _ 0 N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF iL a 1, 4 COM VEH 0 Ea 1 0 V. F. Unknown UnknowrUnknown 0 9 4036704B IL FIRST CONTACT 11 7_;REAR __s *u Yes.See Sidebar U1 Z E TELEPHONE 3TMCZ5ANOHMO59455 unknown ❑Y ❑N U2 I— M in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Vitek. Richard. B. unknown 1 rn `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER L RESPONDER m ❑ DRIVER I} PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 iiuv 0 Ncv 0 CV yr 11- 12 -1 ❑ ® 1 ,� o 13-UNDERCARRIAGE 10;1 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 ❑ ® SPDR 0 ❑Y 0 N ❑UNK VEH. AT CRASH 99-UNKNOWN `0istracton Value U1 9 POINT OF s l 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 1I6 1L_ COM VEH D ® CO FIRST CONTACT 6 Y :j= _s •If Yes,See Sidebar C H AM78844 AZ 0-EAR 9 N M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 1 FDNF6CN7SDF63102 unknown ❑Y ❑N RDEF X EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = U-Haul unknown BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) tSEATI (DOB) (SEX) {SAFT) (AIR) OM (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)r{ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL) U2 996 r m ##OCCS y 71 / / U1 1 D / / 0 E/ MOST EVNT DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 18 9 06,28 /2025 07 00 ®PM in a Work Zone? ®N DIRP co 1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 30 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 2 ❑ 06 18 N 3 ❑ ❑CITATIONS ISSUED 0 PENDING • + ! ❑PM, ❑Construction SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 7 —a ARREST NAME / / 0 PM ' o u El 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT , 05 T 2 ❑ ARREST NAME AM 7 1 r ❑❑PM ❑Unknown work zone type U1 n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 ❑AM Workers present? ❑Y 05 556-Reuter.Craig tot - r ! ❑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- -----------' N - } INDICATE NORTH combination):or -I F �S-- BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C ( +tr 1 _ (example:shuttle or charter bus):or n 1 1 Not To Scale i 3. Is designed to carry 15 or fewer passengers and operated �rated a contract carrier O - ------- i---- - }} } transporting employees in the course of their employment(example:employee � X transporter-usually a van type vehicle or passenger car):or w L L.___a__. 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y• • } • • for direct compensation(example:large van used for specificpurpose):or [he driver, Pe ( P 9 Pe or 0 L L____a____. '' 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 - —I CARRIER NAME Z ADDRESS 0 w '"`ail."' CITY/STATE/ZIP 0 g MOTOR CARR.ID 0 Interstate El Intrastate 1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other -"--------1 - USDOT NO. ILCC NO. rn 73 Source of above 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 ElYes 0 No ❑Unknown Out of Service ❑Yes ❑No Ti 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 TRAILER 2 ❑ 0 0 O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z White White 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 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE