HomeMy WebLinkAbout2025-00047344 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003 984 3
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TWO/ '
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER 91,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
El AMENDED
YR 2025I 2025-00047344 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 �I
® ❑ RELATED ®Y 0 N 07 22 2025 ®AM ❑YES ®NO U1
DUFFY DR Elgin 11:08
_ _ g PRIVATE mo !day!yr ❑PM FLOW CONDITION m
FT!MI N E S W SPARTAN DR COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 cn
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C)
FOR DAMAGEDAREA(S) FRCPtf TOWED U1 Q
Diltz.Charles. E. 0 8 /
yr 13-UNDER CARRIAGE .I FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) al
10 !O DISTRACTED 0 ga U2 0 m
M 2 SYTM IN ENGAGE15-OTHER
4 ❑Y ®SNE❑UNK VEH. 0 AT CRASHD 0 99-UNKNOWN 9 16•TOP 3 `Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 7 ij S �i COM VEH 0 Ea 1 0
I .
ELGIN N I L 60123 0 1 0 FIRST CONTACT 2 7_• -_5 *If Yes.See Sidebar U1
Z AR43805 IL 2026
TELEPHONE
IL D 0 3G NCJ KSBXLL162950 GEICO ❑Y ®N U2 M
19 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Diltz. Mary 4288082532 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER
2 73
x DRIVER ❑ PARKED 0 DRIVERLESS ❑ FED 0 PEDAL 0 Mks 0 Nuv 0 NOV 0 DV
/2 0 0 1 Acura 3.2 TL 1999 00-NONE 11_j Qj-_, DUE TO CRASH 0 p 2 x
0 13-UNDER CARRIAGE 10( I 2 FIRE ID El U2 C
c
M 2 8 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value 9
POINT OF 8 i1�i-4 COM VEH ❑ ® U1 CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 12 7 B .5 •IfYes,See Sidebar
— Evansville IN 47725 0 1 0 915AS IN 2025 I 9 N
D
IN D 0 19UUA5643XA010517 TRAVELERS ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Same 617099292031 BAC
E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND
O N U1 =
(UNIT) (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 ❑Y U2 Z
N 1 CD 11 4 71 /21 /025 11 10 ®❑PM in a Work Zone? NJ N DIRP D
AMco
1 t PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 5 C)
o� T
2 ❑ 23 2 / / ❑PM ❑Construction *
Z 3 ❑ lyg CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM ❑Maintenance U2
o1 ® 11 4 ARREST NAME Diltz.Charles, E. 11-1204-B S408-522 / ! ❑PM SLMT
o N 0 CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
r 2 ❑ ARREST E AM
T ❑❑PM El Unknown work zone type U1
NAM / /
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM ❑Y 30
408-Klinke• Nicholas 702 81 , 61 /025 09 00 ❑PM Workers present? ®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.
.. .. , A CMV is defined as any motor vehicle used to transport passengers or property and: Z
r r• -, I • 01. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
} ____r____; } combination):or —I
} INDICATE NORTH p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
T I1...7
- } (example:shuttle or charter bus):or8prmn?Dr , , , , X
. A A 3. Is desgned to carry 15 or fewer passengers and operated by a contract carrier I O
} } } transporting employees in the course of their employment(example:employee 73
�—� �—• .. . transporter-usually a van type vehicle or passenger car):or 03
L L.___a--_ antsi 1 } } } 4. Is used or designated to transport between9and1�ssen rs,includingthedriver. N
for direct compensation(example:large van used fors specific purpose):or O
14.L L---•a----� + --V � - i i ._ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
9( /T placarding(example:placards will be displayed on the vehicle). X)
'41 ( �/ —DI
CARRIER NAME Z
Not To Scale I - __ ADDRESS
V)
ICITY/STATE/ZIP 0
_ MOTOR CARR.ID 0 Interstate ❑ Intrastate
I I T I I I ❑ Not in Comm./Govt. Not in Comm./Other
USDOT NO. ILCC NO. m
XI
Source of above z
. If Yes,Name on placard 0
4 digit UN NO. 1 digit Hazard class No.
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 ❑ No 0 Unknown M
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 0 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Silver Red
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT' 2 TOWED BY/TO.
Redmons/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE DISABLING DAMAGE NOT DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE