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HomeMy WebLinkAbout2025-00044415 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00388621 u, 9 u21 3 4 1 u1 2 U2 1 U199 U2 1 1.11 99 U2 1 1 10 u, 4 U2 1 *P 9* INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 2 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) El AMENDED ElB Injury and for Tow Due To Crash YR 202512025-00044415 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m WING ST Elgin ® ❑ RELATED ®Y 0 N 07 09 2025 ❑AM ❑YES ®NO U1 -< PRIVATE mo /day/yr 07:50 ®PM FLOW CONDITION m 01 N /MI N E S © North State St COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 2 Co Kane HIT&RUN ®Y ❑ N WITH VEHICLESOT, INVLD ® STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0 18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EDUCE 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n FOR DAMAGEDAREA(S) .FROM TOWED U1 Q Phillips, Lashae.J. 0 2 / yr 13-UNDER CARRIAGE 10 IE 1 ! 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ ❑ U2 m M 9 SY9 ❑Y ❑SNEM®UNK VEH. 9 AT CRASH IN 9 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2 V. CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR F. POINT OF $__;i L S 4 COM VEH 0 Ea 1 0 FIRST CONTACT 99 7 —, _5 *II sees.See Sidebar U1 Z Aurora IL 60506 0 9 0 FL85706 IL 2026 "E TELEPHONE IL D 1 G 1 ZC5E01 CF264889 none ❑v ❑N U2 I— in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Same none 2 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused ❑Y ® N 99 GC) x DRIVER ❑ PARKED ❑DRIVERLESS 0 FED 0 PEON. 0 EWES 0 NMv 0 RDV 0 DV yr 12 o 13-UNDER CARRIAGE 10/ 2 FIRE ❑ ® U2 C c M 2 4 SYSTEM IN 9 ENGAGED 9 15-OTHER 9 16•TOP 3 X ❑Y ❑N ®UNK VEH. AT CRASH 99-UNKNOWN •Oistracton Value 9 0 POINT OF 8 i 4 COM VEH 0 ® u1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6 S_ C FIRST CONTACT I 7 _, _5 •If Yes,See Sidebar ROLLING MEADOWS IL 60008 0 1 0 1194596B IL 2026 REAR 0 Si) IL D 1 GTN 1 LEHOGZ154474 Selective Insurance ❑Y J N RDEF X EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X ALL STATE EQUIPTMENT S2499982 BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP u1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (MI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS))TELEPHONE) (EMS) (HOSPITAL) 2 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z N 1 CD 11 1 07/09 /2025 07 50 ®PM in a Work Zone? NJ DIRP D co 1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 1 n v T 2 ❑ 2 06 1 / ❑PM ❑Construction * Z 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM ❑Maintenance U2 -a, ARREST NAME / / ID PM ' o N El 11 1 ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility SLMT t 2 ❑ ARREST NAMEAM x- T / / ❑❑PM 0 Unknown work zone type U1 n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 0 1560-Jones. Bennett 601 391-Jacobucci / / ❑❑PM Am Workers present? ®N U2 30 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 -' 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 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 1 transporter-usually a van type vehicle or passenger car):or w C L L.___a____.l 1 4. Is used ordesi natedtotrans rtbetween9and15passengers,indudingthedrrver, I I. } } for direct compensation(example large van used for speific purose):or Not To Scale 1 ` I / t l. I I 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires rn 0 I -D placarding(example:placards will be displayed on the vehicle). ,Zmt 411k.:., CARRIER NAME Z t—Z i'z,. . ADDRESS '0 `l l ..„ c D rn ww>+� CITY/STATE/ nZIP 0 W.42 I C 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 . xi Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z own tank)? 0 Yes 0 No 0 Unknown T. 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 ❑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'; ❑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' 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: 1 TOWED BY/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE