HomeMy WebLinkAbout2025-00052174 (2) ILLINOIS TRAFFIC CRASH REPORT Sheet 3 of 4 Sheets HUI III 11 111111
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV
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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. TRFW
Elgin Police Department ONE PERSON'S ❑5501-S1.500 ®ON SCENE 2
VEHICLE/PROPERTY ElOVER 31,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
0 AMENDED YR 202512025-00052174 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 r1
W CHICAGO ST Elgin08:52
® ❑ RELATED ®Y 0 N 08 11 2025 DAM ❑YES IX]NO U1 —<
_ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION m
FT N E S W N EDISON AVE COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW (A
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 --I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
/83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 KW 0 Ncv 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 0
0 9 !
Mitsubishi Outlander 2010 00-NONE OI 0 DUE TO CRASH ® ❑ E
13-UNDER CARRIAGE 10 1 2 FIRE ❑ al C
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 m
F 2 4 SY❑Y ®SNE❑UNK VEH. O AT CRAS IN H O is-OTHER
99-UNKNOWN 9 t6•TOP 3 `Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, i�B 4 COM VEH 0 j$J 1 O
~ ELGIN I N I L 60123 0 1 0 FIRST CONTACT 12 7 ; _-5 *Ir Yes.See Sidebar U1
Z EV34866 IL 2026
TELEPHONE
IL D 0 JA4JT5AX9AZ006262 State Farm ❑Y Il N U2 ni
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Stultz.Steven. F. 1289667SFP13 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
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❑ DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 row
yr 12 _ X1
o 13-UNDER CARRIAGE 10 I c. 2 FIRE 0 0 U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 0 0 SPDR 0
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistraellon Value U1 0 -
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N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR CO
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M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O
❑Y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
BAC
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
RESP❑YD❑N NDER U1 =
(UNIT) (SEAT) (DOS) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0
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EV MOST EVNT LOC, DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 El 11 1 08,11 /2025 08 52 ®PM in a Work Zone? NJ DIRP co
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PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 5 0
rn 1 2 0 ! / ❑PM• ❑Construction
Z3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2
—a, ARREST NAME / / ID PM '
o N 1 ❑ ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility
SLMT
30
t 2 ARREST NAME AM
cf T ! r ❑❑PM ❑Unknown work zone type U1
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n 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y
1515-BellEck.Stacy 601 269-Mendiola 09 !02/2025 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.
0 A CMV is defined as for vehxae used to tra and:
r ----,5-••--, ; any mo nsport passengers or property
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1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -
} }-- -;-- --; } } } r -, , ; ; , ; ( combination):or —I
INDICATE NORTH 71
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ' i 1 , } (example:shuttle or charter bus):or
x
3. Is
L L.___A_. 1 i. <--_- - J transporting edmployeeslin5 hecourseeo theire rsmployment exam pal
e:employeener 73} } }
• � . transporter-usually a van type vehicle or passenger car):or co
< <.__-a-_-_, , < .---_-a-___� , J. , , 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or 0
L L___-a____.I L L L ...._-..i._ 1 t i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). XI
--I
CARRIER NAME Z
i.
ADDRESS 0
th
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other O
USDOT NO. ILCC NO. m
73
Source of above z
) ❑ Side of Truck [0 Papers 0Driver ❑ Log Book m
Z
GVWR/GCWR 1
El <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. P3
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 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
73
IDOT PERMIT NO. WIDELOAD-; ❑Yes 0 No 2
TRAILER VIN 1 m
to
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 3 COLOR U_COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Black
U 3 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO:
Redmons SELECT CODES FROM THE BACK OF CRASH BOOKLET
U_TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO:
DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE