HomeMy WebLinkAbout2025-00050439 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003911946
ut 9 U21 1 1 1 U1 2 U2 1 u199 U2 1 U1 99 U2 99 1 11 U1 11 U211 *P 0119
INVESTIGATING AGENCY DAMAGE TO ANY ❑$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 2
VEHICLE/PROPERTY ®OVER$1,500 ®NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
❑AMENDED YR 202512025-00050439 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m
® ❑ RELATED 0 Y ®N 08 01 2025 ®AM ❑YES ®
PRIVATE NO U1
N RANDALL RD Elgin mo /day/yr 09:10 ❑PM FLOW CONDITION M
COUNTY PROPERTY ❑Y 21 N DOORING ❑y #OF MOTOR 0 SLOW 2 Cl)
00 ®/MI N E 0 W 1-90 WITH VEHICLES INVLD 0 STOPPED U2 —I
El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑V ® N PEDALCYCLIST®N ® FREE FLOW # LNS 0
18:DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑NW ❑!Cy ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
FOR DAMAGEDAREA(S) FRONT TOWED U1 O
Wagner.Jay. H. 0 3 /
yr 13-UNDER CARRIAGE i FIRE ❑ a
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O 2 DISTRACTED 0 !Si U2 2 i11
M 2 4 ❑Y SYSTEM IN ENGAGED 15-OTHER O9 t6.TOP 3 _
❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value ALGN
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF S,_iL S I, 4 COM VEH 0 Ea 1 O
Carmel I N 46032 0 9 FIRST CONTACT 11 7 ;-AR--5 *II Yes.See Sidebar U1
Z OSUGRAY IN 2025
TELEPHONE
IN Other WDDNG86X17A104480 Cincinnati Casualty ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same A011275328 1
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 99
g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES ❑iiuv 0 i v ❑DV
/1 9 6 8 Ford F150 2019 13-NONE 'o,1 t2 c,�2 FIRE DUE O CRASH 0 ® U2 2 C
o yr 13-UNDER CARRIAGE
c
M 2 4 SYSTEM IN ENGAGED 15-OTHER 911,6•TOP 3 9 X
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraglon Value U1
POINT OF 8 i1�I" 4 COM VEH ❑ ® CO
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 6
FIRST CONTACT 5 71 1 —_,SOS •If Yes.See Sidebar
Naperville IL 60565 0 1 2809204B IL 2025 IO C
IL D 1 FTEW1 E46KFC80822 Acuity ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 99 =
BTI Communications ZR56984 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE;ZIP
U1 =
(UNIT) (SEAT) (DOBi (SEX) {SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME(/(ADDRESS)/(TELEPHONE! (EMS) (HOSPITAL)
1 6 10 /
/ / UI 3 D:A
/ / 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 1 08/04 /2025 11 00 ®❑PM in a Work Zone? ®N DIRP co
1 T PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 5
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 ❑ 28 03
N 3 0 0 CITATIONS ISSUED 0 PENDING + / ❑PM• El Construction >F
SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM ❑Maintenance U2
—a ARREST NAME / / ID PM '
o, N 1 ® 11 1 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility SLMT
❑ 45
T 2 El ARREST NAME AM
/ / ❑PM El Unknown work zone type U1
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 El AM Workers present? ❑Y 45
540-Dykema.Tracy - / / ❑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 unitshave been moved prior to officer's arrival.
IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A
I ADDITIONAL UNITS FORMS.
I
J
r ----r••--, , I I I L 0
, 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 -<
c ` -' -' r_ _ _ _ INDICATE NORTH combination):or -I
IBY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
_ (example:shuttle or charter bus):or
X
L A - 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
} } } transporting employees in the course of their employment(example:employee X
— — — MOtransporter-usually a van type vehicle or passenger car):or c0
L L.___a__. 4. Is used ordesi natedtotrans transport passengers,including y- } } } g po passen rs,includi the driver,
I for direct compensation(example:large van used for specific purpose):or
O
i. i 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires
a I placarding(example:placards will be displayed on the vehicle).
m
XI
- , ,
I Not To Seale CARRIER NAME Z
!� O
L L L L. 1..__ ADDRESS
D
! •IN
' ,. CITY/STATE/ZIP 0
_ i. MOTOR CARR.ID 0 Interstate 0 Intrastate
' ❑ Not in Comm./Govt. ❑ Not in Comm./Other 00
I. ------- I - i- USDOT NO. ILCC NO. C
m
r XI
Source of above z
. ❑ Yes 0 No 0 Unknown E
D
Did Carrier Safety Regulations MCS)violation contribute to the crash?
❑ 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'; 0 Yes 0 No 2
TRAILER VIN 1 m
Cn
LOCAL USE ONLY TRAILER VIN 2 m
0
TRAILER WIDTH(S) 0-96" 97-102" >102' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Silver White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO:
_Other . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE