HomeMy WebLinkAbout2025-00051090 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111
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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 ❑$501-$1.500 ®ON SCENE 14
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
0 AMENDED YR 2025I 2025-00051090 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 -n
PARK ST EIIn
® ❑ RELATED ' V 0 N 08 07 2025 01:27 IZIAM ❑YES El NO U1
_ _ g PRIVATE mo !day/yr ❑PM FLOW CONDITION m
FT!MI N E S W HILL AVE COUNTY PROPERTY ElY ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ Kane HIT&RUN ®Y ❑ N WITH VEHICLES INVLD ❑ STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 n
! ! FOR DAMAGEDAREA(S) FROM TOWED U1 Q
Unknown.0. Toyota Crown 00-NONE „ •
12 i DUE TO CRASH ❑ EN
NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 10 IE
1 ! 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 25 m
9 9 SYSTEM IN g ENGAGED g 15-OTHER 9 16.TOP 3 _
❑Y ❑N ®UNK VEH. AT CRASH ®-UNKNOWN `Distraction Value 9 ALGN
s 4.4- CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF )�S 1i,_ 1
1*. FIRST
9 0 FIRST CONTACT 11 7__; COM VEH 0 j$J_5 *IIYes.See&debar U1
0
REAR
2 Z ' E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 11/
Unknown ❑Y ❑N U2 m
5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
co
99 9 Same Unknown 2 1-
5 HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
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N DRIVER 0 PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NvV 0 NCv 0 DV
!1 9$7 Tesla Model 3 2023 00-NONE 'o,� t2 (,-2 FIRE DUE o CRASH ® U2 2 C
o 13-UNDER CARRIAGE
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M 2 4 SYSTEM IN 9 ENGAGED 9 15-OTHER 9.1,6•TOP 3 X
❑Y ❑N ®UNK VEH. AT CRASH 99-UNKNOWN *Oistraglon Value 9 g
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF O1 S l;, 4 COM VEH ❑ ® Ut CO
FIRST CONTACT 7 O7 �,�==Q�._5 •If Yes.See Sidebar
Z SOUTH ELGIN IL 60177 0 1 0 73571 EL IL 2025aR Si)0
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IL D 0 5YJ3E1EA7PF582549 Tesla ❑Y ®N RDEF71
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same TLAILA9993FVEL BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPOND 0 N u1 =
KNIT) (SEAT) (0081 (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(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 4 08,07 l2025 01 27 ®❑AM
in a Work Zone? ®N DIRP co
1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 1 n
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v 1 2 ❑ 23 2 ) ! ❑PM ❑Construction X
Z 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 7
❑AM ❑Maintenance U2
- N ® _ • 0 Utility
a ARREST NAME / / ❑PM '
1 1 1 4 0 CITATIONS ISSUED ❑PENDING SLMT
o, SECTION CITATION NO. ROAD CLEARANCE TIME
AM 25
t 2 El ARREST NAME 08/07 12025 02 00 MPM ❑Unknown work zone type u1
n T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 0 ❑AM Workers present? ❑Y 25
449-Harris,Jacob 301 331-Ziegler , / ❑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••--, , ; 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- }---.r----; } combination):or
INDICATE NORTH �
1 1 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
(example:shuttle or charter bus):or n
3. Is designed to carry15 or fewer passengers and operated a contract carrier O
I. } } transporting employee in the course of their employment(example:employee
—.41 I
L�� ® transporter-usually a van type vehicle or passenger car):or w
L L.___a__..� 4. Is used ordesi natedtotrans transport passengers,urns C
MO* — — } } • •
for direct compensation(example:large van used for specific purpose):or 0
L L.._-a____.: — — — r — — — t i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
Qoy I I i placarding(example:placards will be displayed on the vehicle). XI
—I
_40 I T CARRIER NAME Z
N __ ADDRESS 'O
' D
Not To Scale I I CITY/STATE/ZIP 5
MOTOR CARR.ID 0 Interstate ❑ Intrastate
I I T I ❑ Not in Comm./Govt. 0 Not in Comm./Other
------- --1 - USDOT NO. ILCC NO. rn
XI
Source of above Z
. 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
Xl
IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2
TRAILER VIN 1 m
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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
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT 9 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BYlT6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE