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HomeMy WebLinkAbout2025-00051162 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 011011001 I 0OI 001 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X403917343 u, 1 u21 1 1 1 U116 U2 1 U199 u2 1 U, 1 U2 1 1 11 U1 1 U2 1 *P 0119* INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away AGENCY CRASH REPORT NO. TRFW ' Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 10 VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT) 0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00051162 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 2 �I ROUTE 20 Elgin ® ❑ RELATED 0 Y ®N 08 07 2025 ®AM ❑YES ®NO U1 -< PRIVATE mo /day/yr 11.56 ❑PM FLOW CONDITION M • 1 O COUNTY PROPERTY ❑Y ® N DOORING ICIy #OF MOTOR IR SLOW 1 (n ® �i/MI N E S © Grace St WITH VEHICLES INVLD ❑ STOPPED U2 —I ❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑V ® N PEDALCYCLIST IZI N ❑ FREE FLOW # LNS 0 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 NIAV 0!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 1 n r tf TOWED U1 O Teaue. FOR DAMAGEDAREA(S) FRO Timothy. 0 5 / yr 13-UNDER CARRIAGE ©,I �:. 2 FIRE 0 IR STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0U2 1 M M 2 4 ❑Y ®N SYSTEM ❑UNK VEH. 0 AT CRASHO 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s it S Ii 4 COM VEH 0 0 1 n I— FIRST CONTACT 11 7__�_-_;__5 *IrYes.See Sidebar U1 0 Z Cumming GA 30040 0 1 0 DBQ4747 GA 2025 R TELEPHONE GA C 9 1 C6RR7KT8RS1 57975 Old Republic Insurance Co ❑Y ®N U2 m 13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER RSUR m 99 9 Quiktrip Corporation MWTB318914 1 rn `o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 98 0 ��, N DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL ❑EWES ❑Nov 0 KV ❑Dv CIRCLE NUMBER(S) U1 1 9 9 1 Kia Motors COlporento 2018 00-NONE 'o,I t2 (,-2 FIRE DUE OCRASH D ® U2 2 C o 13-UNDER CARRIAGE 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 *0istrac on Value 9 3 POINT OF 8 i 4 COM VEH D ® U1 CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR 5 FIRST CONTACT 6 O7 ,�=QIOS •It Yes.See Sidebar C Belvidere IL 61008 0 1 0 FL98157 IL 2026 i0 Si) IL D 0 SXYPG DA53JG417278 Kemper ❑Y ®N RDEF X EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 9 = 99 9 Same 12RA000031169 BAc E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER U1 = (UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(A.DDRESS)/(TELEPHONE) (EMS) (HOSPITAL) 1 3 01 / 7/ / / UI 2 D / / 2 0 co U EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME ®AM Did crash occur ®Y U2 Z N 1 ® 11 1 81 l 12 /25 11 56 ❑PM in a Work Zone? ❑N DIRP D 1 t PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7 T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 � 0 2 0 28 03 / / ❑PM ®Construction * Z 3 0 xi CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 7 ❑AM ❑Maintenance U2 o ® 11 1 ARREST NAME Teague.Timothy.W. 11-601 1540-304 / / ❑PM SLMT o N ElCITATIONS ISSUED ElPENDING SECTION CITATION NO. ROAD CLEARANCE TIME 0 Utility 0 AM T 2 El ARREST NAME 81 //2 /25 12 57 ®PM El 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 1540-Allahi. Muhammad 401 91 / 12 /25 01 30 ❑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 e---•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 -< c ` -' -' r INDICATE NORTH combination):or .Z-1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C 1 - (example:shuttle or charter bus):or I r r r 0 ` A 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I 0 } } } transporting employees in the course of their employment(example:employee X < <.___a____� ltI . 1C transporter4. sedord si natedtotransportbetween9a dr15p ssen rs,includingthedriver. C /), L. m m } } } for direct compensation(example:large van used for specific purpose):or L L--_•a iJ ( t 1 r-I D .f - i } i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m mr — „ — — —0— . 3—'"°'-0—' —0"'-0 '® placarding(example:placards will be displayed on the vehicle). XI _ _ 2).�0 of 0 � o a ® — CARRIER NAME Z I - ........ ADDRESS D Not Tb sods CITY/STATE/ZIP 0 0 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 -I 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 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 Gray u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 1 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/T6 DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE