HomeMy WebLinkAbout2025-00047055 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 011011000 0101 10 1111111
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003695302*
u, 9 U21 1 1 1 U1 5 U216 U199 1_12 1 u1 99 U2 99 1 11 u1 1 U2 1 *P 0119*
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 f or Tow Due To Crash YR 2025I 2025-00047055 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m
LILLIAN ST Elgin
® ❑ RELATED ❑Y ®N 07 21 2025 ®AM El YES ®NO U1
PRIVATE mo /day/yr 08:42 ❑PM FLOW CONDITION m
®20 0/MI NOS W South Mclean Blvd COUNTY PROPERTY El'COUNTY 21N DOORING Ely #OF MOTOR 0 SLOW 1 (n
Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I
0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
(8:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
/ FOR DAMAGEDAREA(S) FROPtf TOWED U1 0
Unknown.O. Unknown Unknown 00-NONE „ 12 , DUE TOCRASH ❑ EN
NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 101 ! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3
9 9 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN =
s 4 COM VEH ❑ Ea r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF _,I[6 !I,_ 1 00
I- 0 9 FIRST CONTACT 99 7_; _5 *lIYes.See Sidebar U1
REAR
2 Z ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1)
unknown ❑Y ❑N U2 I-
13 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 ❑Y ® N 99 0
�{ DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NMV 0 Ncv 0 DV
2 0 0 0 Hyundai Sonata 2011 00-NONE 11-. 12 0 DUE TO CRASH ❑ (� 2
Tiy yr 13-UNDER CARRIAGE 10 1 i., 2 FIRE ❑ ® U2 C
F 2 4 SYSTEM IN ENGAGED 15-OTHER 9 16-TOP 3 9 X
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistrac on Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-it 6 1l, COM VEH ❑ ® U1 CO
FIRST CONTACT 1 Y , _6 •(ryes,See Sidebar
m SOUTH ELGIN IL 60177 0 1 FG52809 IL 2025 REAR
C
M
IL D SNPEB4AC4BH127131 Direct Auto ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Same PAIL011167350 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER®N U1 =
KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 9 07,21 i2025 09 40 ®❑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 ❑ 20 99
N 3 ❑ 0 CITATIONS ISSUED 0 PENDING + ) ❑PM• El Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM El Maintenance U2 3
—a ARREST NAME / / ID PM '
o, N ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT
30
r 2 ARREST NAME AM
7 1 r ❑❑PM ❑Unknown work zone type U1
El
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 30
540-Dykema.Tracy 701 — r / ❑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
Not To Scale ( 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
` ` --I -' r INDICATE NORTH combination):or —I
73
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
I I I (example:shuttle or charter bus):or 0
I 3. Is designed tocarry 15 or fewer passengers and operated a contract carrier O
L.
pa g pe
-- } } } transporting employees in the course of their employment(example:employee 73
transporter-usually a van type vehicle or passenger car):or co
i. }-----}. ..I. - - - . . . •4. Is used or designated to transport between 9 and 15 passengers,including the driver.for direct compensation(example:large van used fors specific purose):or
L L____a____� � _ t i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)thatrequires 'D
placarding(example:placards will be displayed on the vehicle). XI
-I
— — CARRIER NAME Z
-Z`LIIarNR \ __ ADDRESS 0
CITY/STATE/ZIP 0
- 1 MOTOR CARR.ID 0 Interstate 0 Intrastate 5
' ❑ Not in Comm./Govt. ❑ Not in Comm./Other 00
----------1 - USDOT NO. ILCC NO. C
m
XI
Source of above 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?
❑ Yes II No ElUnknown 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
co
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' m
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Blue.Dark
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 9 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE