HomeMy WebLinkAbout2025-00046209 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
I0110110011 0111010 100
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003694:47-
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 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 14
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
El AMENDED
YR 2025I 2025-00046209 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I
® ❑ RELATED ®Y 0 N 07 17 2025 ®AM ❑YES 21 NO U1
ALFT LN Elgin 11:45
_ g PRIVATE mo !day!yr ❑PM FLOW CONDITION m
FT!MI N E S W CAPITAL ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD DO
U2 —I
CO AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N 51 FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 MAU 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C)
FROhrr TOWED U1 Q
NAME(LAST,FIRST,M) Sheldon. Barbara.A. mo Toyota RAV4 2020 00-NONE �, O _, ODE TO CRASH ® ❑
O 13-UNDER CARRIAGE I ' FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 2 DISTRACTED 0 0 U2 0 m
F 2 SYTHER
4 ❑Y ❑SNE®UNK VEH. 9 AT CRASH IN ENGAGED9 99-UNKNOWN 9 t6-TOP 3 `Distraction Value 9 ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6, it 6 �i COM VEH 0 j$J 1 0
I . ELGIN IL 60124 0 1 0 FIRST CONTACT 11 7_; __S *IIYes.See&debar U1
Z BU62512 IL 2026 REAR
TELEPHONE
IL D 2T3F1 RFV3LW110491 State Farm ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same 1331015SFP13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 2 c
x DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 MAv 0 NOV 0 Dv
!1 9 yf 3 Hyundai Sonata 2021 00-NONE 0. Q!'-O DUE TO CRASH rg ❑ 2 x
...
13-UNDER CARRIAGE 10( I 2 FIRE ❑ ® U2 C
c
F 2 4 SYSTEM IN 9 ENGAGED 9 15-OTHER 9,16-TOP 3 X
❑Y El ®UNK VEH. AT CRASH 99-UNKNOWN *0istraglon Value 9 U1 0
POINT OF 8 i1�. 4 COM VEH 0 ® W
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 12 7� B .S •(ryes,See Sidebar
— Hampshire IL 60140 0 1 0 G604343 IL 2026 I 0 C
IL D 5N PEG4JA9M H 120355 State Farm ❑Y ®N RDEF M
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Same 1039180SFP13 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused 0 Y°ND
O N U1 =
(UNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 4 co
07;17 l2025 11 45 ®❑PM AM in a Work Zone? ®N DIRP D
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 �
Si 2 ❑ 23 28 ( ( ❑PM ❑Construction *
R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM ❑Maintenance U2
ou 1 ® 1 1 4 ARREST NAME Sheldon. Barbara.A. 11-1204-B 410000741 / ! El PM SLMT
o N
0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility
r 2 ❑ ARREST NAMEAM
c- T ❑PM ❑Unknown work zone type U1
( / ❑
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 30
410-DeLeon.Jessica 901 08 ; 19,2025 01 30 ®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••--, , ; 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
combination):or -<
' I I } INDICATE NORTH p0
c A BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
, I (example:shuttle or charter bus):or C). .
r7I
i N , 3. Is designed to car 15or fewer ssen ers and o rated a contract carrier/ - } } } transport) em loyees in the courses of their em yment(example:employee Ta transporter-usually a van type vehicle or passenger car): r
I I I I "•' C
i. ---' acorn :rr;<;.: C
-- - } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver, to
III = ; for direct compensation(example:large van used for specific purpose):or o
` .I. Unit - L } } } 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle).
—1
CARRIER NAME Z
I I t ADDRESS 'n
V)
CITY/STATE/ZIPn
MOTOR CARR.ID 0 Interstate 0 Intrastate
I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other
�" --- --1 USDOT NO. ILCC NO. m
XI
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. XI
XI
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 VIM 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
Gray Blue
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO.
Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® DISABLING DAMAGE Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE