HomeMy WebLinkAbout2025-00052078 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets Mill III H IIIl
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANV XO03921906
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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 El$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500
El NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and for Tow Due To Crash YR 202512025-00052078 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED PRIVATE ❑Y ®N 08 11 2025 12,—AM ❑YES El NO U1 -<
N RANDALL RD Elgin mo /day/yr 01.57 ®PM FLOW CONDITION m
10(� COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR IR SLOW 15
® 1C.'J!MI N E O IA, 1-90 _ WITH VEHICLES INVLD ❑ STOPPED U2 --1
O AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Cook HIT&RUN I2J Y ElN PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0
g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EOUES 0 Nuv 0 ncv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 C)
0 6 /
yr 13-UNDER CARRIAGE 10.I 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 3 <<T1
M SY❑Y ®SNEM❑UNK VEH. 0 ATCRASHD 0 15-OTHER 99-UUNKNOWN 9 16•TOP 3 `DistractionVatue ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s it_�a COM VEH 0 0 1 n
I— FIRST CONTACT 12 7_ ,__5 *II Yes.See&debar U1 0
... ELGIN IL 60123 0 FB68862 IL 2025 REAR
TELEPHONE
IL D 0 1 HGCM55837A009066 United Equitable Insuranc ❑v I l N U2 13 . m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same ILU0123456 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF`Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
r D Y°®N 0
m g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES 0 row 0 KCV 0 DV
yr Ford Escape 2009 00-NONE 00•O DUE TO CRASH ❑ 2 x
o 13-UNDER CARRIAGE 10,i I.. 2 FIRE 0 El U2 C
c
M SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.7OP 3 X
❑Y El ❑UNK VEH. AT CRASH 99-UNKNOWN •Oistraelion Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF
�i 5 I' COM VEH ❑ ® U1 COI— FIRST CONTACT 6 l:!�:,-wr.A •
Des Plaines IL 60016 0 A895009 IL 2026aR If Yes.See Sidebar 0 N
IL D 0 1 FMCU93GX9KB47132 American Family Insurance ❑Y ®N RDEF 7)
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Bare,Sherri.A. 2111648501 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP
ui =
i(JNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
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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 ® 11 1 08,11 ,2025 01 57 ®PM in a Work Zone? ®N DIRP co
1 I 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 , , ❑PM• ❑Construction
1
R 3 0 $I CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 1
❑AM 0 Maintenance U2
oEl 11 1 ARREST NAME Wiskirchen.Thomas, E. 11-601-Ax 1515-000720 , r El PM SLMT
o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility
45
t 2 11 1 ARREST NAME AM
7 El r ❑❑PM El Unknown work zone type U1
2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑y 45
1515-BellEck,Stacy 502 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.
r ----r••--, , I ( A CMV is defined as any motor vehicle used to transport passengers or property and: Z
Not To Scale 1.c Has a weight rating more than 10,000 pounds(example:truck or truck trader -I i 1. >
�' y y I INDICATE NORTH p1
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver
} ......... r r r (example:shuttle or charter bus):or 0
A 1� 3. Is desgned to carry 15 or fewer passengers and operated by a contract carrier I O
--� } } } transporting employees In the course of their employment(example:employee 73
transporter-usually a van type vehicle or passenger car):or co
L -----}----+ ar. - I. } } } •4. Is used or designated to transport between 9 and 15 passengers,including the driver, N
M for direct compensation(example:large van used for specific purpose):or O
__ _ l. i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle). XI
—1
CARRIER NAME Z
ADDRESS 0
to
T.
0
CITY/STATE/ZIP
g
MOTOR CARR.ID 0 Interstate 0 Intrastate
1 I r 1 ❑ Not in Comm./Govt. 0 Not in Comm./Other
; _Y_ __1 USDOT NO. ILCC NO. m
XI
Source of above z
'
. 0 Yes 0 No ❑ Unknown A
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
Red Gray
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ElNOT DISABLING DAMAGE DAMAGE EXTENT 2 TOWED BY/TO:
_ SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO:
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE