HomeMy WebLinkAbout2025-00044039 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ®5501-$1.500 ®ON SCENE 7
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 2025512025-00044039 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 7 71
1151 TIMBER DR Elgin12:05
® ❑ RELATED ❑Y ®N 07 08 2025 ❑AM ❑YES ®NO U1 -<
_ _ PRIVATE mo /day/yr ®PM FLOW CONDITION MCOUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR ❑SLOW 7 Cl)
❑ FT/MI N E S W Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
Q83 DRIVER I] PARKED I]DRIVERLESS 0 PED CI PEDAL 0 EWES 0 uMv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 n
FOR DAMAGEDAREA(S) FROr4tr TOWED U1 Q
NAME(LAST,FIRST,M) Wildfong.Jason. E. 0 3 /
yr 13-UNDERCARRIAGE 101 •!. 2 FIRE 0 IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 14 U2 0 r11
M 2 4 ❑Y ❑N SYSTEM
®UNK VEH. 9 AT CRASH D 9 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 1 B �i 4 COM VEH ® 0 1 0
.`,2 1- Fruit port M I 49415 0 1 0 FIRST CONTACT 1 7_. -__5 *I(Yes.See Sidebar Ut
Z P RC23487 MI 2025 iivui
TELEPHONE
MI A 7 3AKJGLDR7KSKK8537 Amerisure Mutual Ins Co ❑Y ®N U2 13 . m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m
co
JVC Enterprises Inc CA21124410502 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET.CITY.STATE,ZIP PHONE NUMBER
RESPONDER
21 0
0 DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 Nuy 0 i v 0 Dv
yr 13-UNDER CARRIAGE ta,i 2 FIRE 0 ® U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR n
a SYSTEM IN 9 ENGAGED 9 15-OTHER 9 16•TOP 3
❑Y ❑N ®UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 U1 0
POINT OF ) 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR ,._ COM VEH El 0 CO
F„ FIRST CONTACT 11 7 , _5 •If Yes.See Sidebar
3712582 IN 2026 REAR 0 Si)
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
3AKBHKDR7SSVM0501 Safeco Insurance Company ❑Y 123 N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 X
XPO Logistics Freigh 6524239 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
)INIT1 (SEAT) (D081 (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)(TELEPHONE) (EMS) (HOSPITAL)
2 1 08 / M 1 3 0 1
m
/ / #OCCS D
71
/ / U1 1 D
/ / 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 18 5 07,08 l2025 12 05 ®AM in a Work Zone? ®N DIRP co
I I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 2
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
Fsi 2 0 14 18
N 3 0 CITATIONS ISSUED 0 PENDING / ! 0 PM• ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 1
2
-a, ARREST NAME / / ❑PM '
o N ® 11 5 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
SLMT
10
r 2 ARREST NAME AM
7 1 r ❑❑PM 0 Unknown work zone type U1
El
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 10
410-DeLeon.Jessica 501 - 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.
A CMV is defined asmotor vehicle used to transportand:
r ----,5-•---, ; any passengers or property
Z
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
} i.-- -i-- --; } } } r -, , ; ; , 1, ( INDICATE NORTH combination):or —I
p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ' , } (example:shuttle or charter bus):or
X
3. Is L L.___A_. 1 i. - -___� J transporting employened to es Inhecourse 5 or fewer o their eers mplod yment example:employeener X
} } }
transporter-usually a van type vehicle or passenger car):or co
I- <.__-a-_-_-I , l• I- I- <--_-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____.: L L L ...._-..i.____� l. i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires III
placarding(example:placards will be displayed on the vehicle). XI
i.
.-1CARRIER NAME Peterson Farms Z
ADDRESS 3104 W BASELINE RD 0
T.
, CITY/STATE/ZIP Shelby 1 M I !49455 g
MOTOR CARR.ID El Interstate ❑ Intrastate
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other O
Y- --4 I- I- Y- ; ; ; USDOT NO. 2784734ILCC NO. m
XI
Source of above z
own tank)? 0 Yes ® No 0 Unknown
Did HAZMAT Regulations violation contribute to the crash? r
❑ Yes ❑ No 0 Unknown g
D
Did Carrier Safety Regulations(MCS)violation contribute to the crash?
❑ Yes II No ❑ Unknown A
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 UYVS2533L6981815 m
co
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ® 0 0 Z
TRAILER 2 0 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 53 ft. 2 ft. Z
White White
u 1 TOWED TOTAL VEHICLE LENGTH 70 ft. NO.OF AXLES 5
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 0 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. 6 CARGO BODY TYPE LOAD TYPE