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HomeMy WebLinkAbout2025-00049036 I LLI NOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets Mil III H IIII DIII 0110 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003903931 u, 1 U2 1 1 1 U1 9 U2 U, 1 1_12 U, 1 U2 1 1 9 U123 U222 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 1 VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00049036 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 21 mBERKLEY ST Elgin ® ❑ RELATED ❑Y ®N 07 29 2025 12,— ❑YES ElPRIVATE NO U1 mo /day/yr 01.49 ®PM FLOW CONDITION m �O C.'J!MI N E S ® Second St COUNTY PROPERTY ❑Y 21N DOORING ❑y #OF MOTOR 0 SLOW 1 cn Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD 0 STOPPED U2 --I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0 18:DRIVER I] PARKED I]DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NW 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 1 n 1 0 / 13-UNDER CARRIAGE 101 12 2 FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 m M 2 4 ❑Y ❑N SYSTEM ❑UNK VEH. 0 AT CRASH D 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF $ it 8 �i 4 COM VEH 0 0 1 0 ~ Philadelphia PA 19154 0 1 0 FIRST CONTACT 6 7. . -_5 *II Yes.See Sidebar Ut V. Z P AH44912 PA 2025 Isui TELEPHONE PA A 7 1 FUJHHDR6LLKX009 Progressive ❑Y ®N U2 m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m LP POWER LLC 003201300 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF IC OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 21 (,0j ❑ DRIVER X. PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 NMv 0 NOV 0 DV / yr Tesla Model 3 2019 I -NONE 1 i 2 j.-_1 DUE TO CRASH ❑ ® 1 "'I 0 13-UNDER CARRIAGE Oi ©!c 2 FIRE 0 ® U2 C Ti SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ® SPDR C) SYSTEM IN 9 ENGAGED 9 15-OTHER 9.16 COTOP 3 9 0 X a ❑Y ❑N UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value POINT OF 8 it . -4 Ut N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 12 7A—jt5 C•OM Sidebar ® CO ~ 8KHC720 CA C REAR 0 M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0 5YJ3E1 EB3KF368109 unknown ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X Clark. Douglas unknown BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP U1 = {UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) OM (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 18 1 07,29 i2025 01 49 ®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 2 0 30 99 N 3 0 0 CITATIONS ISSUED 0 PENDING • + ) ❑PM• ❑Construction SECTION CITATION NO. EMS ARRIVED TIME ❑AM 0 Maintenance U2 7 -a ARREST NAME / / ❑PM ' o N ® 11 1 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • ❑Utility SLMT , 30 t 2 ARREST NAME AM 7 1 r ❑❑PM 0 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 1531 Sch�mbach.Jack 702 , ❑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 -< ` ` --I -' r INDICATE NORTH combination):or .Z-1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C i_ I 0 - r (example:shuttle or charter bus):or 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I A O } } } transporting employees in the course of their employment(example:employee X ... transporter-usually a van type vehicle or passenger car):or CO L i.. i Not To Scale f - } 1} 4. Is used or designated to transport between 9 and 15 passengers,including the driver, C for direct compensation(example:large van used for specific purpose):or O L L____a..... a°"0°""a t ii. , 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m placarding(example:placards will be displayed on the vehicle). ;p -- CARRIER NAME Z ADDRESS 0 V) C) CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate ❑ Intrastate 0 I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other -"-----"1 - USDOT NO. ILCC NO. 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? 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 Z TRAILER 2 ❑ 0 0 o u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w White Blue u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 0 TOWED BY/TO: _ SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO. DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE