HomeMy WebLinkAbout2025-00045340 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 10110110011 00011 11000
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV *X0036.87170*
u, 9 U29 1 1 1 U, 2 U299 U199 U299 u,99 U2 1 4 9 u, 1 U221 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY ®5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 7
VEHICLE/PROPERTY ❑OVER$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and f or Tow Due To Crash YR 202512025-00045340 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 71
1100 S RANDALL RD Elgin09:15
® ❑ RELATED ❑Y ®N 07 13 2025 DAM ❑YES ®NO U1 —<
_ g PRIVATE mo /day/yr ®PM FLOW CONDITION MCOUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ FT/MI NESW Kane HIT ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I
ID AT RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER I] PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 1 C)
/ ! FOR DAMAGEDAREA(S) FRONT TOWED U1 0Unknown.0. Other Other 00-NONE EN
it. 12 , DUE TO CRASH ❑
NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE IE
101 ! 2 FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED U2 1 <
9 9 SYSTEM IN 9 ENGAGED 9 15-OTHER 9 16.TOP 3 ❑ _
❑Y ❑N ❑UNK VEH. AT CRASH ®-UNKNOWN `Distraction Value 9 ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s_iL B I,.4 COM VEH 0 j$J 1 0
I— 0 9 0 FIRST CONTACT 99 7_( __5 •0Yes.See Sidebar U1
ZUNKNOWN Unknown REAR
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1)
unknown 0 Y 0 N U2 I—
.9 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same unknown 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused 0 Y ® N 99
0 DRIVER X. PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 Nuv 0 NOV 0 DV
/ yr 10' 12 c, 2 FIRE 0 ® U2 2 C
Ti 13-UNDER CARRIAGE
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP3 0 ® SPDR n
❑Y ®N DUNK VEH. AT CRASH 99-UNKNOWN `Oistraci n value Q 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF O' - it 4 COM VEH 0 ® ut COF,,, Q 6 l FIRST CONTACT 7 'ts •If Yes.See Sidebar
ED33962 IL 2025 REARO N
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
4S3BNBC62F3031134 First Chicago ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Metcalf.Sean. B. pall 015684-00 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (00B) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
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 07,13 /2025 09 15 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 ❑ 06 99
N 3 ❑ 0 CITATIONS ISSUED 0 PENDING ! 1 0 PM• El Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 6
z
—a, ARREST NAME / / El PM
o N 1 ® 11 5 0 •
CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT
AM15
Ti 2 ❑ ! r ❑❑PM ❑Unknown work zone type U1
ARREST NAME
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ 1531-SchEmbach.Jack 801 391-Jacobucci ! ! ❑❑PM Workers present? ®N U2 15
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 - ; 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 -<
}
i- ____r__--; u combination):or
INDICATE NORTH p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
j. _ } (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
L L.___a__ 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including C' 1 / -` - } } for direct compensation(example:::large van used for speific purpose):ordi the driver.
r
O
< i..._-a____. ,_ . - } } } _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
' // placarding(example:placards will be displayed on the vehicle). m
/, s A
�/ Z
CARRIER NAME Z
ADDRESS 0
w
C)
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I T I ... -� ❑ Not in Comm./Govt. Not in Comm./Other
I I I
Not To Scale °
USDOT NO. ILCC NO. rTt
Source of above z
. —I
Were HAZMAT placards on vehicle? 0 Yes 0 No =
If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. Xl
Xl
Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z
own tank)? 0 Yes 0 No 0 Unknown
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' -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
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ElNOT DISABLING DAMAGE DAMAGE EXTENT 9 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. CARGO BODY TYPE LOAD TYPE