HomeMy WebLinkAbout2025-00053194 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets II Ill1111111111111 IIIIII 011001011111111111011 III
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003925005
u, 1 U21 1 1 1 U, 4 U2 1 U, 1 1_12 1 U, 1 U2 1 1 11 U1 1 U211 *P 0119*
INVESTIGATING AGENCY DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ® q 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
❑NOT ON SCENE(DESK REPORT)
0 AMENDED IDB Injury and/or Tow Due To Crash YR 202512025-00053194 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rl
® ❑ RELATED PRIVATE ❑Y ®N 08 15 2025DAM ❑YES ®NO U1
S MCLEAN BLVD Elgin mo /day/yr 03:27 ®PM FLOW CONDITION M_
®25 ® O COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR El SLOW 3 Cl)
!MI N E S W Carr St WITH VEHICLES INVLD El STOPPED U2 --I
El AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Kane HIT&RUN ❑V ® N PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
tg:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 4 n
FOR DAMAGEDAREA(S) FRONT TOWED U1 O
Stare. Kell E. 0 5 /
yr ol 13-UNDER CARRIAGE 1a./ 2 ' 2 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 4 <<n
F 2 SY 15-OTHER
4 ❑Y El ❑UNK VEH. O AT CRASH M IN D 0 99-UNKNOWN 9 76•TOP 3 *Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 7_iL a I,.4 COM VEH 0 )21 1 C)
F. FIRST CONTACT 12 7_:—, _5 *If Yes.See Sidebar tit
Z SOUTH ELGIN IL 60177 0 1 0 AG97341 IL 2025
TELEPHONE
IL D 0 KNAE35LC4K6055323 Allstate ❑Y ®N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 811 650 232 1 r
'6HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER >
Refused ❑Y ® N 2 XI
p; DRIVER ❑ PARKED 0 DRIVERLESS ❑ PED 0 PEDAL ❑EWES 0 i My 0 KCV 0 DV
Yr
/1 9 6 3 Toyota Sienna 2021 00-NONE ,�_i 12 -_, DUE TO CRASH p (� 2
0 13-UNDER CARRIAGE to l z FIRE ❑ ® U2 C
c ij
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16.TOP 3 X
❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN *OistracI Dn Value 9 0
POINT OF s i 4 COM VEH ❑ ® Ut CO N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR -II 6 1'._
FIRST CONTACT 6 Y__{_O ._5 •IfYes.SeeSidebar
— Wheaton IL 60189 0 1 0 CU15038 IL 2026 i 0 C
IL D 0 STDYSKFC9MS026366 Statefarm ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST.M) POLICY NUMBER 1 =
99 9 Same 2393367SFP-13 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
(UNIT) (SEAT) (DOB' (SEX) {SAFT) (AIR) (INJ) 1(EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
3 6 04 /
:A
/ / UI 1 D
/ / 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 1 8/ /5/ /025 03 28 ®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
O 2 28 03 / / 0 PM 0 Construction *
R 3 ❑ $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
❑AM 0 Maintenance U2
o1 ® 11 1 ARREST NAME Stare. Kelly. E. 11-601 1559000042 / / El PM SLMT
S' N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility
ID r 2 0 11 1 ARREST NAME AM
7 / / pM 0 Unknown work zone type 30
U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT I DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 20
1559-DavE los.Yoana 601 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••--, , 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 -<
Unit I Not To Scale 1 combination):or —I
r r 'i---- ----, - I. INDICATE NORTH p1
7: rn BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i_ ; i i i (example:shuttle or charter bus):or
° a T,
•f_i
3. Is designed to carry 15 or fewer passengers and operated by a contract career i O
- } I.- } transporting employees In the course of their employment(example:employee 73
r, transporter-usually a van type vehicle or passenger car):or CO
all
} } 1 •4. Is used or designated to transport between 9 and 15 passengers,including the driver. N
Untt 3
,`T for direct compensation(example:large van used for specific purpose):or O
L L____a____� o.on t i. i t 5. Is any vehicle used to transport anyhazardous material(HAZMAT)that requires m
1 I
placarding(example:placards will be displayed on the vehicle). XI
—1
r CARRIER NAME Z
ADDRESS 0
w
C)
CITY/STATE/ZIP g
MOTOR CARR.ID 0 Interstate 0 Intrastate
r ; ❑ Not in Comm./Govt. ❑ Not in Comm./Other 00
Ialwagensmal - i. USDOT NO. ILCC NO. m
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
to
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
White Silver
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 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE