HomeMy WebLinkAbout2025-00046534 ILLINOIS TRAFFIC CRASH REPORT sheet 1 Df 2 Sheets II
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ElB Injury and/or Tow Due To Crash YR 202512025-00046534 VENT
ADDRESS NO. HIGHWAY or STREET NAME El ❑CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 mRT20 RELATED ®Y 0 N 07 18 2025 08:58 DAM ❑YES ®NO U1 -<
Elgin PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W HIGHLAND WOODS BLVD COUNTY PROPERTY ❑Y 2�1 N DOORING ❑y #OF MOTOR ❑SLOW 1 (n
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD DO
STOPPED U2 -I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0
(g)DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0 wcv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
0 7 /
yr 13-UNDER CARRIAGE 101 12! 2 FIRE 0
IE
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 0 171
M 2 SY15-OTHER
4 ❑Y ®SNE❑UNK VEH. 0 AT CRASH M IN ENGAGED0 99-UNKNOWN 9 16•TOP 3 ,Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s it 6 Ii,4 COM VEH 0 jK 1 C)
H Z Gary IN 46407 0 1 0 4146972B IL 2006 FIRST CONTACT 7 O_;REAR
__s Yes.See Sidebar U1 0
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TELEPHONE
IN Other 0 1D7HA18N26J173808 Unknown ❑Y ❑N U2 m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same Unknown 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 98 0
N DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED 0 PEDAL 0 EWES 0 NMV 0 Ixv 0 DV
� /1 9 6 9 FR
^ NAME(LAST,FIRST,M) Kettner.Christopher.J. Ford Explorer 2018 00-NONE 0. Qi'-_, DUE TO CRASH ❑ 73 2
0 Yr 13-UNDER CARRIAGE 10( I 2 FIRE 0 ® U2 C
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y ®N DUNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 9 g
i1 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF -, Ii 4 COM VEH 0 ® U1 CO
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FIRST CONTACT 11 8 7 , _s •(ryes,See Sidebar
— Genoa IL 60135 0 1 0 FF21434 IL 2026 REAR g
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IL C 0 1 FM5K8AR6JGC74433 StateFarm ❑Y ®N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 0209104SFP13 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (D08) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((A.DDRESS)((TELEPHONE) (EMS) (HOSPITAL)
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 4 07,18 /2025 08 58 ®PM in a Work Zone? ®N DIRP co
1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 5 C)
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2 0 2 99 / / ❑PM• ❑Construction *
R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM 0 Maintenance U2
a 1 ® 11 4 ARREST NAME Pickett. Montsho. N. 11-901.01 1530000423 / / El PM SLMT
igi CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
o N ❑AM 15
t 2 El ARREST NAME Pickett. Montsho. N. 3-707 1530000424 , / ❑PM 0 Unknown work zone type U1
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 15
1530-Soto.Oscar 801 08 ,05/2025 09 00 ❑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.
Hxthlanrr.".tiok,rt:..-,i
r ----r••--, , - A CMV is defined as any motor vehicle used to transport passengers or property and: Z
�____r____; I 1. Has
or more than pounds(example:truckortrucktrailer 1. Has a weight rating10 000 � -<
INDICATE NORTH tan):
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
C
i_ - } (example:shuttle or charter bus):or 0
3. Is designed to carry15 or fewer passengers and operated a contract carrier O
}} } transporting employee �In the course of their employment(example:employee
transporter-usually a van type vehicle or passenger car):or CO
L L.___a____� 4. Is used ordesi natedtotrans rtbetween9and15passengers,includingthedriver. C
1 I } } } for direct compensation(examp large van used for speific purose):or N
"" ./ .. UnR 2. } t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
_ placarding(example:placards will be displayed on the vehicle). XI
``,\ CARRIER NAME Z
G,�• � ADDRESS D
7 \ (A
CITY/STATE/ZIP 00
- i. i. i. 4. MOTOR CARR.ID 0 Interstate 0 Intrastate
II ❑ Not in Comm./Govt. ❑ Not in Comm./Other 00
‘I. Not To Scale 1 i.
USDOT NO. ILCC NO. C
m
x
Source of above z
. 0 Yes 0 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 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
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LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 0 ❑ 0 z
11
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. z
White 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 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE