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HomeMy WebLinkAbout2025-00053407 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 I011011001 0101111 DIV II DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003925609 u, 9 U21 2 4 1 U1 3 U2 1 U,99 1_12 1 U199 U2 1 1 10 u, 4 U2 11 *P 0119 INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S El$501-$1.500 0 ON SCENE 14 VEHICLE/PROPERTY ®OVER$1,500 ®NOT ON SCENE(DESK REPORT) El AMENDED ElB Injury and for Tow Due To Crash YR 202512025-00053407 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 71 SLADE AVE El In12:45 ® ❑ RELATED ' V 0 N 08 16 2025 ❑AM ❑YES ®NO U1 _ _ g PRIVATE mo !day/yr ®PM FLOW CONDITION m FT N E S W DOUGLAS COUNTY PROPERTY El ® N DOORING ❑Y #OFMOTOR El SLOW 1 U.)❑ Kane HIT ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I ® &RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 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) FROPtf TOWED U1 Q Unknown.O. Unknown Unknown 00-NONE it.. 12 , DUE TOCRASH 0 NAME{LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 16 !�. 2 FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3 9 9 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN O 4 `Distraction Value ALGN = CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST NTOONTACT F 7 Q 114f__5 *COM VEH 0 ZgJ 1 0 o Z 0 9 0 UNKNOWN I ves.seesidabar Ut E TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 1/ Unknown ❑Y ❑N U2 I— in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m 99 9 Same Unknown 1 rn `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Refused El ® N 99 GC) m g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 II/AV 0 NCV 0 DV CIRCLE NUMBER(S) U1 '1 9 yf 9 Chevrolet Spark 2021 00-NONE Q.i �p DUE TO CRASH ❑ 2 o 13-UNDERCARRIAGE 10.j ©l( 2 FIRE ID ElU2 C lij c M 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16•TOP 3 X 0 Y ®N 0 UNK VEH. AT CRASH 99-UNKNOWN ''OistraclIon Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-it 6 1l, COM VEH ❑ ® U1 CO FIRST CONTACT 1 7� -5 •If Yes.See Sidebar H E LG I N IL 60120 0 1 0 CS46089 IL 2025 REAR 0 N IL D 0 KL8CA6SA5MC700693 Bristol West ❑Y ®N RDEF P3 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X 99 9 Same G01664966200 BAG $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPONDER®N U1 = (UNIT) (SEAT) (DOB) (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 CD 11 4 08,16 l2025 01 59 ®PM AM in a Work Zone? NJ DIRP > co 1 t PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 1 C) Si 2 ❑ 23 2 ) / 0 PM ❑Construction * Z 3 0 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3 ❑AM ❑Maintenance U2 -a, ARREST NAME ! ! El PM ' o u ® 11 40 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • El Utility SLMT r 2 ❑ ARREST NAMEAM T / / ❑❑PM 0 Unknown work zone type U1 n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ❑ ❑AM Workers present? 0 Y 30 1558-Lundvick.John 102 , / ❑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 -< ` ` -' -' r INDICATE NORTH combination):or —I BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C i_ - } (example:shuttle or charter bus):or X ® Not To Scale I ism ] fo 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier O . - . transporting employees In the course of their employment(example:employee transporter-usually a van type vehicle or passenger car):or co i. }-----}----l. - • } I- 1 •4.r Is useddirect or designatedcompensation(example:to transportlarge betweenvan 9used andfor 15speci passenficpurp rsose,inc):orlu ding the driver, ow L t i i 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires 'D unsi placarding(example:placards will be displayed on the vehicle). XI —1 CARRIER NAME Z r r -1- 1 MI . , L. 1.. ...... ADDRESS n CITY/STATE/ZIP g MOTOR CARR.ID 0 Interstate ❑ Intrastate I I . I ❑ Not in Comm./Govt. 0 Not in Comm./Other ------- --1 - USDOT NO. ILCC NO. rn XI Source of above 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 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: 2 TOWED BY/TO. DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE