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HomeMy WebLinkAbout2025-00041811 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 011011000 0 00 lI fll 11011 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003670393 u, 1 U21 1 1 1 U1 8 U2 1 U1 1 u2 1 U1 1 u2 1 1 12 U1 18 u2 1 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY 0 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) El AMENDED ❑ B Injury and for Tow Due To Crash YR 2025I 2025-00041811 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n ® ❑ RELATED ❑Y ®N 06 30 2025 ®AM ❑YES ®NO U1 -< RT20 EB Elgin PRIVATE mo /day/yr 10:46 ❑PM FLOW CONDITION m �O 1C.'J!MI N E S © South State St COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 7 Cl) Kane HIT&RUN ❑V ® N WITH VEHICLESOT, INVLD DO STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS O 18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n 1 1 / EN yr 13-UNDERCARRIAGE 101 �. 2 FIRE 0 IE STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m M I 2 SY6 ❑Y ®SNE❑UNK VEH. O AT CRASH M IN D 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN x r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF it �i,4 COM VEH ❑ j$J 1 n " F. La Salle I L 61301 0 1 0 FIRST CONTACT 1 O7 _; __5 *If Yes.See&debar U1 0 ZV437553 IL 2025 REAR TELEPHONE IL D 0 5N1AT2MVOKC783346 Owners Insurance ❑Y ®N U2 19 . m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same 52-555-063-00 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER > Refused ❑Y ® N 2 0 x DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED 0 PEDAL 0 EWES 0 uv 0 NCv 0 Dv 1 9 5 7 Other Other 2022 00-NONE 11 ' t2---0 DUE TO CRASH 0 (g► 21 o Yr 13-UNDER CARRIAGE I FIRE ❑ ® U2 M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X ❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istracton Value 9 0 8 i1 4 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s L - COM VEH El El U1 CO FIRST CONTACT 1 Y _, _5 • — Eagle WI 53119 0 1 0 406472 WI 2026 REARIfYes.See Sidebar 0 N WI A 7 3AKJHHDRXNSNF7954 Acuity Mutual ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 = Veterans Truck Line zq2389 BAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS),(TELEPHONEI (EMS) (HOSPITAL) U2 996 r m #occs y 71 / ,, U1 1 D 1 0 E/ MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 ® 11 1 61 ,01 ,025 10 46 ®❑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 o" 2 0 20 99 / , 0 PM ❑Construction * 4 R 3 0 $ 3 I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 o1 ® 11 1 ARREST NAME Stariha. Michael.j. 11-709-C 1531000094 / ! El PM SLMT o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility 55 f 2 ARREST NAME AM 7 1 r ❑❑PM 0 Unknown work zone type U1 El 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 55 1531-SchEmbach.Jack 701 81 , 21 ,025 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 -< ` ` -' -' r INDICATE NORTH combination):or —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 • transporti3. Is ng mployeened to sl5 or fewer in the course passengers thir emplod yment example:employee transporter I. r } transporter-usually a van type vehicle or passenger car):or NOf TO SCBIA J I 1* } } } •4. Is used or designated to transport between 9 and 1 passengers,rs,including the driver, co C i. �. - --i _ _, . evaxr,er for direct compensation(example:large van used fors specific purpose):or• O i }< <____a }....� - -�.r ! _ I _ L } L 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 17 ,,, placarding(example:placards will be displayed on the vehicle). XI RnuleTle , , , , , CARRIER NAME Veterans Truck Line Z I - ADDRESS 800 BLACK HAWK DR 0 w CITY/STATE/ZIP Burlington 1 WI 153105 g MOTOR CARR.ID El Interstate El Intrastate 0 I r Not in Comm./Govt. 0 Not in Comm./Other ;....Y._._.; USDOT NO. 46576 ILCC NO. m XI Source of above z . ❑ Yes 0 No 0 Unknown g D Did Carrier Safety Regulations(MCS)violation contribute to the crash? A ❑ Yes I 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. WIDELOAEP 0 Yes ®No 2 TRAILER VIN 1 1 graa0626gw700886 m 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 0 o u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 53 ft. 2 ft. w Black Orange u 1 TOWED TOTAL VEHICLE LENGTH 53 ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO: _ SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO. DUE TO ® VEHICLE CONFIG. 3 CARGO BODY TYPE 2 LOAD TYPE 9