HomeMy WebLinkAbout2025-00046031 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003694:42
u, 9 U21 1 1 1 U199 U2 1 u1 99 u2 1 u1 99 U2 1 1 12 u, 18 U2 1 *P 0119�K
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 1215501-$1.500 ®ON SCENE 3
VEHICLE/PROPERTY ❑OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 2025I 2025-00046031 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m
® ❑ RELATED PRIVATE ❑Y ®N 07 16 2025 ❑AM ❑YES ®NO U1
N RANDALL RD Elgin mo /day/yr 12:45 ®PM FLOW CONDITION m
01 D95!MI• O E S W BIG TIMBER Rd COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 7 Cl)
Kane HIT&RUN I2J V ❑ N WITH VEHICLESOT,
INVLD DO
STOPPED U2 -I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
183 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV ❑DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 5 C)
yr 13-UNDER CARRIAGE 161 !�. 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 5 M
SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3
9 9 ❑Y ❑N ❑UNK VEH. AT CRASH ®-UNKNOWN `Distraction Value ALGN
s 4 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _ _6 1i,_ COM VEH 0 Ea 1
H 0 9 0 FIRST CONTACT 99 7 : _5 *II Yes.See&debar U1
0
REAR
2 Z ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1)
UNK. Ely ❑N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same UNK. 1 I-
`o HOSPITAL(TAKEN TO) INCIDENT IF`Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
r D Y°N0 N 0
m N DRIVER ❑ PARKED ❑DRIVERLESS ❑ FED ❑PEDAL 0 EWES ❑liPAV 0 I<Cv ❑DV CIRCLE NUMBER(S) U1
1 9 yf 3 Volvo VNL760 2019 00-NONE .1.,-1 12..-_, DUE TO CRASH 0 ® 98 x
o 13-UNDER CARRIAGE 'IFIRE ❑ ® U2
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9I1,6-TOP 3 X
a`
❑Y ®N El UNK VEH. AT CRASH 99-UNKNOWN `Oistraglon value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-iI 6 ij:, COM VEH El ❑ U1 CO
FIRST CONTACT 2 Y , _5 •(ryes,See Sidebar
=Z MACON GA 31220 0 1 0 P1231421 IL 2026 REARD
GA A 4V4NC9EH3KN214295 ACORD ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
LESSEE/BLACK SEA TRA GL013823B BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP 996 <
RESPONDER
Y°O N U1 =
iUNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
u 1 ® 11 1 07!16 ;2025 12 45 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
2 ❑ 20 99
N 1 3 0 0 CITATIONS ISSUED 0 PENDING / / ❑PM• ❑Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5
-a, ARREST NAME / / ❑PM '
o N ® 11 1 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT
45
t 2 ARREST NAME AM
7 El r ❑❑PM 0 Unknown work zone type U1
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
❑Y 45
244-Blomberg. Michael 901 ! / ❑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.
r ----r••--, , I I ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z
r I 1.c Has aor more than pounds(example:truck or truck trailer i 1. Hasa weight rating10 000 5Z
A INDICATE NORTH tan): -I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
N _ (example:shuttle or charter bus):or 0
i. i_ ..;----; I transportinrg employeened to vsl5 or fewer in the courses passengers
then emand pbyment operated
xample:employeener 73
pa'T -. } F }
` `- "_-' "' J Not To Scale - 4.Is used or des gnated to transport between 9 a d 15rpa ssen rs,including the driver,
CO
} } } for direct compensation exam I lar a van used fors cific ur
o J ( P 9 Pe P �):or
L L____a____� z l. i i t 5. Is anyvehicle used to transport anyhazardous material(HAZMAT)that requires m
g placardig(example:placards will be isplayed on the vehicle). XI
• - ` J
CARRIER NAME BLACK SEA TRANSPORTATION LLC
i g ADDRESS 37W370 IL RT. 38
Oi _
D
co
CITY/STATE/ZIP ST.CHARLES i IL 160175 M
II _ MOTOR CARR.ID 0 Interstate El Intrastate
I r ❑ Not in Comm./Govt. ❑ Not in Comm./Other
t 0
------""1 I I i. i. USDOT NO. 2331239 ILCC NO. C
m
XI
Source of above z
. 0 Yes 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 ®Unknown Out of Service ❑Yes ®No C
Z
Form Number 0
m
P3
IDOT PERMIT NO. WIDELOAD? ❑Yes ®No 2
TRAILER VIM 1 m
co
LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' -n
TRAILER 1 0 ® 0 Z
TRAILER 2 ❑ 0 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 53 ft. 2 ft. w
u 1 TOWED TOTAL VEHICLE LENGTH 70 F ft. NO.OF AXLES 5
DUE TO ❑ DISABLING DAMAGE El 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: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. 6 CARGO BODY TYPE 2 LOAD TYPE 9