HomeMy WebLinkAbout2025-00050158 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets lUI
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV X003921932
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and for Tow Due To Crash
0 AMENDED YR 2025I 2025-00050158 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED ❑Y ®N 08 03 2025 El ❑YES ®NO U1
ST CHARLES ST Elgin03:17
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FT!MI N E S W DWIGHT ST COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 cn
❑ Kane HIT ®Y ❑ N WITH VEHICLES INVLD ❑ STOPPED U2 --I
CO AT RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IZI N ® FREE FLOW # LNS 0
Qgl DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑uuv ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
0 4 !
yr 13-UNDER CARRIAGE 161 !:. 2 FIRE ❑ al
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL O4-TOTAL(ALL) DISTRACTED ❑ 0 U2 2 m
M 2 SY8 ❑Y ®SNE❑UNK VEH. 0 AT CRASH M IN D 0 99-UNKNOWN 9 16•TOP 3 *Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6 iL 6 ii,a COM VEH 0 j$J 1 0
~ Hampshire IL 60140 B 1 0 FIRST CONTACT 1 7_; __5 *lIVes.SeeSidebar Ut
Z P FH22809 IL 2025 REAR
TELEPHONE
IL D 0 1HGEM21913L006073 NIA ❑Y ❑N U2 I--
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 99 9 Same NIA 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Provena St.Joseph ❑Y El 2 0
N DRIVER ❑ PARKED ❑DRIVERLESS ❑ FED ❑PEDAL 0 EWES ❑row 0 i v ❑Dv
!1 9 9 3 Jeep(after 1961�)npass 2018 00-NONE ,._"j t2..-_, DUETO CRASH rg ❑ 2 x
oay yr 13-UNDER CARRIAGE 10;1 2 FIRE ❑ ® U2 C
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M 2 8 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16•TOP 3 X
❑Y Ni N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistracl on Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s ii 6 �.-_e COM VEH D ® U1 W
F„ FIRST CONTACT 11 7 _5 •IfYes.See Sidebar C
ELGIN IL 60120 A 1 0 EV80978 IL 2025 " 0 Si)
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IL D 0 3C4NJDCB7JT246099 AMERICANALLIANCE ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same I LAA-1061638-00 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Provena St.Joseph RESPOND 0 N U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 1 08/03 ,2025 03 17 ®❑AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1 C)
2 0 23 2 08,03 ,2025 03 17 pM
❑ • ❑Construction �E
Z 3 ❑ O CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
®AM ❑Maintenance U2
—a, ARREST NAME 08,03,2025 03 24 ❑pM '
1 ® 11 1 0 CITATIONS ISSUED PENDING UtilitySLMT
o N SECTION CITATION NO. ROAD CLEARANCE TIME 0
AM u, 30
r 2 ❑ ARREST NAME 08/03 ,2025 04 21 [�PM ❑Unknown work zone type
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ 1541-Wilkerson.Tondeo 401 331-Ziegler , , ❑❑PM Workers present? ®N U2 30
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••--, , ; 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 N INDICATE NORTH combination):or -I
XJ
.BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
(example:shuttle or charter bus):or 0
lerteavuxesrexl X
.� 3. Is desgned to carry 15 or fewer passengers and operated by a contract carrier I O
i nror to y. - I. } . transporting employees In the course of their employment(example:employee CO
I `.'— transporter-usually a van type vehicle or passenger car):or CO
I. } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver, C' — — for direct compensation(example:large van used for specific purpose):or O
L L____a____ t 5 Isan vehcleusedtotransportan hazardous material(HAZMAT)thatrequires
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/ / placarding(example:placards will be displayed on the vehicle). m
I I CARRIER NAME Z
Q I _ 0ADDRESS
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rn
":-- CITY/STATE/ZIP 0
MOTOR CARR.ID 0 Interstate El Intrastate
0
. I . . ❑ Not in Comm./Govt. 0 Not in Comm./Other
--'-------1 - USDOT NO. ILCC NO. m
XI
Source of above z
. 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
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. Z
White Greenw
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO.
Arties/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET
u 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO:
DUE TO ® Arties/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE