HomeMy WebLinkAbout2025-00052287 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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XIII III 111111H
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV 03919998
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INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW '
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and for Tow Due To Crash YR 2025I 2025-00052287 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 m® ❑ RELATED PRIVATE ❑Y ®N 08 12 2025 ®AM El YES El NO U1 -<
N STATE ST Elgin mo /day/yr 08:36 ❑PM FLOW CONDITION m
�Q ® O COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ®SLOW 2 Cl)
!MI N E S W Frazier Ave WITH VEHICLESOT,
INVLD ❑ STOPPED U2 —I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑V ® N PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) 4 0
Y N
0 7 /
yr 13-UNDER CARRIAGE I ! FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) EN
O ' 2 DISTRACTED 0 0 U2 4 M
M 2 4 ❑Y ❑SNEM®UNK VEH. 9 AT CRASHIND 9 99-UNKNOWN 9 16•TOP 3 *Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, i�a �i COM VEH 0 j$J 2 O
F. Lake In The Hills IL 60156 0 1 0 FIRST CONTACT 11 7_; __5 *rives.SeeSidebar U1
Z 178691F IL 2026 REAR
TELEPHONE
IL D W1Y9EC3YXMT076465 Pekin Insurance ❑v ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR
Jim Keller Kitchen B 005845567 2 m
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER
14 0
p; DRIVER ❑ PARKED 0 DRIVERLESS ❑ FED 0 PEDAL 0 EWES 0 ivy 0 NCv ❑DV
2 O O O NT Chevrolet Silverado 2023 00-NONE ,�_' 12..-_, DUE TO CRASH ❑ 21 14
o 13-UNDER CARRIAGE 0 O I 2 FIRE ID El U2 C
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M 2 4 SYSTEM IN 9 ENGAGED 9 15-OTHER 9.16•TOP 3 X
❑Y ❑N ®UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value 9 0
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H CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT 1 O O7 �1171--:-4 CIO e1sVEH SeeSidebar❑ ® U1 cC
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Z STREAMWOOD IL 60107 0 1 0 3748063B IL 2026aR
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IL D Ace American Insurance Co ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
Autozone Parts Inc ISAH11373756 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
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KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!{ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
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71
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EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 1 81 ,21 ,025 08 36 ®❑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 �
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2 0 28 20 1 , ❑PM ❑Construction *
Z 3 0 El CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM 0 Maintenance U2
a ® 11 1 ARREST NAME Wilson. Luke. M. 11-701-A 410000745 / r El PM SLMT
o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility
35
T 2 ARREST NAME AM
7 1 r ❑❑PM 0 Unknown work zone type U1
El
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 35
410-DeLeon.Jessica 501 9/ , 6/ ,025 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 ----r••--, , - I 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 truckrtrailer -
" combination):INDICATE NORTH combination �
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
A ( _ (example:shuttle or charter bus):or
N '_ 3. Is designed to carry15 or fewer passengers and operated by a contract carrier O
I 1 I�
} } } transporting employee in the course of their employment(example:employee °
l R"""?k transporter-usually a van type vehicle or passenger car):or co
L 4. Is used or designated to transport between 9 and 15 passengers,including N
}--- - _ - } } } g po passen rs,indudi the driver,- 1 f.
for direct compensation(example:large van used for specific purpose):or O
L L--_-a-.... - L i I 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
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placarding(example:placards will be displayed on the vehicle). XI
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L L _
' CARRIER NAMEADDRESS
._na Tosw._�
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CITY/STATE/ZIP g
I _ MOTOR CARR.ID 0 Interstate El Intrastate
r ; ❑ Not in Comm./Govt. 0 Not in Comm./Other
----------1 - USDOT NO. ILCC NO. rn
XI
Source of above z
. If Yes,Name on placard 0
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
White White
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 2 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE