HomeMy WebLinkAbout2025-00043583 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets II
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X0038 956
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INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 2025I 2025-00043583 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
316 ADAMS ST Elgin01:02
® ❑ RELATED ' ' 0 N 07 06 2025 ®AM ❑YES El NO U1 -<
_ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ FT/MI N E S W Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 —I
O AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER O PARKED D DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 MN 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
FOR DAMAGEDAREA(S) FRO TOWED U1 Q
NAME(LAST,FIRST,M) Unknown.O. mo !
13-UNDER CARRIAGE 10 i 2 FIRE 0 IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED U2
9 9 SYSTEM IN 9 ENGAGED 9 15-OTHER 9 16-TOP 3 ❑ ' _
❑Y ❑N ElUNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 9 ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6_iL 6 4 COM VEH 0 j$J 1 0
~ 0 9 FIRST CONTACT 12 7_; _5 *lIVes.SeeSidebar U1
Z EX55262 IL 2025 REAR
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1
1 G4CW53LXM 1701607 Unknown ❑Y ❑N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Turner. Lakisha. M. Unknown 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
r D Y°®N ( GC)
5, 0 DRIVER I} PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 M/v 0 CIRCLE NUMBER(S) U1
NO! 0 Dv
yr g +t_� ,z -' ❑ ® 1
Ti 13-UNDER CARRIAGE 10;I c. 2 FIRE ❑ ® U2 C
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ ® SPDR C)
SYSTEM IN 0 ENGAGED 0 15-OTHER 9.16-TOP 3 9 9 X
a ❑Y i N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istrac Dn Value
POINT OF 6 ) -4ut
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6 COM VEH D ® CO
F,,, FIRST CONTACT 6 O7 ,�=QI_5 •If Yes.See Sidebar
2510999B IL 2025 REAR 9 N
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
1 C6RR7HT5DS590105 Allstate ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Rea.Valente.G. 802324702 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOE) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
W 1 0 /
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 18 1 07,06 /2025 01 02 ®❑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
2 0 28 18
N 3 ❑ CITATIONS ISSUED 0 PENDING + ! ❑PM- El Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 3
-a, ARREST NAME / / El PM '
1 ® 1 1 1 ❑CITATIONS ISSUED PENDING UtilitySLMT
N SECTION CITATION NO. ROAD CLEARANCE TIME
o 0
AM U1 35
t 2 0 ARREST NAME 07 r 06 12025 01 02 [M PM 0 Unknown work zone type
n T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 1513-Mann. Nathaniel 701 331-Ziegler , / ❑❑PM Workers present? ®N U2 35
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 truck trailer -<
c ` --I -' r INDICATE NORTH combination):or .Z-1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
® _ } (example:shuttle or charter bus):or
X
L A 3. Is designed to carry 15 or fewer passengers and operated by a 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
I. L.___a__. 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y
s,rn� } } } for direct compensation(example::large van used for speific purpoe):or
the driver.
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i. i t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
. placarding(example:placards will be displayed on the vehicle). m
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Wilt CARRIER NAME Z
ADDRESS
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0
Not To Scale I CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
-"--------1 - USDOT NO. ILCC NO. rn
XI
Source of above z
. 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. WIDELOAD'; 0 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 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Black Black
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 9 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