HomeMy WebLinkAbout2025-00044898 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 0110110011 0011111 111101111M 11/11100
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003E-86191
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ❑OVER$1,500 El NOT ON SCENE(DESK REPORT)
El AMENDED ElB Injury and/or Tow Due To Crash YR 2025512025-00044898 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED ®Y 0 N 07 11 2025 ❑AM ❑YES ®NO U1 -<
BLUFF CITY BLVD Elgin04:20
_ _ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W ELIZABETH ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD DO
U2 —I
Igl AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑NW ❑!CV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
FOR DAMAGEDAREA(S) FRONT TOWED U1 Q
Schue, Matthew.J. 0 2 !
yr 13-UNDER CARRIAGE -) FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 10 h O DISTRACTED 0 0 U2 4 <<Tl
M 2 SYTM IN ENGAGETHER
4 ❑Y ®SNE El UNK VEH. 0 AT CRASH 0 99-U15-UNKNOWN 9 16-TOPO ,Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 ;i� 6 �I COM VEH 0 Ea 1 0
F.
Elgin IL 60123 0 1 0 FIRST CONTACT 2 7 : -_5 *u Yes.See Sidebar U1
Z 9 3162132B IL 2025 Ismi
TELEPHONE
IL D 0 3GCPYBEKXMG425157 State Farm ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 1742058-SFP-13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Refused 0 Y El 2 0
N DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑ uv 0 N v ❑DV
!1 9 yf 9 Honda Accord 2008 00-NONE ,t_' 12'" , DUE TO CRASH ❑ C 2
0 O 13-UNDER CARRIAGE I 2 FIRE 0 El U2 C
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F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 0916•TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istracton Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR PONT OF
FIRST CONTACT 10 711 6 L_5 CIOMesvSeeSidebar❑ N I U1 CO
H ELGINZ IL 60123 0 1 0 AZ85696 IL 2025 REAR Si)0
M
IL D 0 1 HGCP26768A143826 Allstate ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 974584958 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
u 1 ® 11 1 07,11 /2025 04 20 ®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 �
0
2 06 99 ) 1 0 PM ❑Construction *
1 4
R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
- U2
a, ARREST NAME Schue, Matthew,J. 11-708 (w)455-430 / ! ❑❑PM ❑Maintenance SLMT® 1 1 1 •
❑CITATIONS ISSUED ❑PENDING MT
o N SECTION CITATION NO. ROAD CLEARANCE TIME
ElUtilit y
t 2 El ARREST NAME 071 1 1 12025 04 20 ®PM El Unknown work zone type U1 40 0 AM
n T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 455-HallaE.Gabriel 401 391-Jacobucci , / ❑❑Pmm� Workers present? ®N U2 45
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
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1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
} i.-- -i-- --; ; } } } i- -, , ; ; , ; ( INDICATE NORTH combination):or —I
p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ' i I , } (example:shuttle or charter bus):or
X
3. Is L L.-_------ 1 <--_- -___� 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 c0
< <.__-a-_-_- , l• < <--_-a-___� . , , , 4. Is used ordesi nated to trans rt between 9 and 15 passengers,including C} } for direct compensation(example:large van used for specificpurpose):or [he driver,
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L L-. ..i.. -_.: L L L ...._-.�_ ; l. i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). m,Zt
CARRIER NAME Z
ADDRESS 0
, n
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other 0
USDOT NO. ILCC NO. m
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
0
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Blue Silver
u 1 TOWED TOTAL VEHICLE LENGTH 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: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE