HomeMy WebLinkAbout2025-00050479 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 011011001 I 10
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XO039115 8
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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 0$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
ID AMENDED
YR 2025I 2025-00050479 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
N STATE ST El 02:18
® ❑ RELATED ®Y 0 N 08 04 2025 12,— ❑YES ®NO U1 -<
_ _ g PRIVATE mo !day!yr ®PM FLOW CONDITION MFT!MI N E S W KIMBALL BALL ST COUNTY PROPERTY El ® N DOORING ID #OF MOTOR ID SLOW 5 Cl)
❑ Kane HIT ❑Y ® N WITH VEHICLES INVLD IN STOPPED U2 -I
igl AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) &RUN PEDALCYCLIST IZI N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑NOV ❑!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 n
1 0 /
yr 13-UNDER CARRIAGE } O FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 ]$I U2 3 M
M 2 SYTM 3 ❑Y ®SNE DUNK VEH. O AT CRASH 0 99-UNK 15- NOWN THER9 76•TOP 3 *Distraction Value ALGN
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r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s iI B �i 4 COM VEH 0 j$J 1 0
H F.
Hanover Park I L 60133 A 1 0 FIRST CONTACT 1 7_: -_s *IIYes.See Sidebar U,
Z62126AV IL 2025 REAR
TELEPHONE
IL D 0 VC5SA07638 AMERICAN MODERN ❑Y ®N U2 13 . m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 99 9 Same 100678997 1 1—
"6 HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Provena St.Joseph ❑Y ® N 2 GC)
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Eg DRIVER ❑ PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 NIAV 0 NCV 0 DV
!1 9 yf 8 Unknown Unknown 2007 00-NONE 11-. 12 (,-2 FIRE DUE o CRASH ® U2 33 C
o - 13-UNDER CARRIAGE
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M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9.1,6•TOP 3 X
❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value 3
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8 1 S .t. 4 COM VEH ❑ ® ut CO
I� FIRST CONTACT 6 O7 ,�=Q)OS •IfYes.SeeSidebar C
ELGIN IL 60124 0 1 0 M172653 IL 2025 REAR Si)0
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IL D 1 N9MNAC6X7C084085 Self Insurance ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
Elgin Fire 99 9 Pace Divsion 1 BAC
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HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
U1 =
(UNIT) (SEAT) (DOB) (SEX) (SAFT) (AIR) (INJI 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME))(A.DDRESS)/(TELEPHONEI (EMS) (HOSPITAL)
2 7 08 /
LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ID U2
N 1 ® 11 1 8/ //2 /25 02 18 Z
®PM AM in a Work Zone? ®N DIRP D
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1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
o, 2 0 28 99 8/ //2 /25 02 02 ®PM 0 Construction *
R 3 0 xi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM ❑Maintenance U2
a 1 ® 11 1 ARREST NAME Albrecht. Dennis. L. 11-601 1535000230 8/ //2 !25 02 22 0 PM• • ❑Utility SLMT
igi CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM
o Nt 2 El ARREST NAME Albrecht. Dennis. L. 11-305 1535000231 8/ //2 /25 03 15 0 PM 0 Unknown work zone type U1 35
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y 35
1535-Solis, Laura 601 269-Mendiola 8/ / 6/ /025 01 30 El NI ®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----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- ----'-----' I I spa - } INDICATE NORTH combination):or -I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
— — — ' _ (example:shuttle or charter bus):or
r r r 0
I- I- --I--
3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
} I.- } transporting employees in the course of their employment(example:employee X
1 transporter-usually a van type vehicle or passenger car):or co} } 1- 4. Is used or designated to transport between 9 and 15 passengers,including the driver. N
r r for direct compensation(example:large van used for specific purpose):or O
L i.____a____� — _ � } } } _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)thatrequires
' placarding(example:placards will be displayed on the vehicle). XI
— — — u,.r —.ma _ - —1
CARRIER NAME Z
` 1 ADDRESS 0i D
'1 I l I 0
CITY/STATE/ZIP g
25 C
3 i. i. i. MOTOR CARR.ID 0 Interstate 0 Intrastate
0
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
----- -"'- - USDOT NO. ILCC NO. rn
XI
Source of above Z
. GVWR/GCWR m
0 <10,000 0 10,000-26,000 0 >26,000 z
Were HAZMAT placards on vehicle? 0 Yes 0 No =
If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No. Xl
Xl
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 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
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 Blue
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
_Mies/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE