HomeMy WebLinkAbout2025-00053895 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Of 4 Sheets Mill III H IIII
DIII 00110001001111 IlIlIHIOlI
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003926455
u, 1 U21 1 1 8 U199 U299 U, 1 u2 1 U, 1 U2 1 1 11 U1 13 U2 2 *P 0119*
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-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER 51,500 ❑NOT ON SCENE(DESK REPORT)
El AMENDED ❑ B Injury and f or Tow Due To Crash YR 202512025-00053895 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
® ❑ RELATED PRIVATE ❑Y ®N 08 18 2025 ❑AM ❑YES ®NO U1 -<
DUNDEE AVE Elgin mo /day/yr 03:45 ®PM FLOW CONDITION m
_
Igi25 ®/MI N E O W Seneca St COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR IR SLOW 2 u)
Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST IR N ❑ FREE FLOW # LNS 0
(8)DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑NOV ❑!CV ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
0 9 /
yr
13-UNDER CARRIAGE 10l 12! 2 FIRE 0 NI
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0THER 0 U2 2 m
F 2 4 SYTM❑Y ®SNE DUNK VEH. 0 AT CRASH 0 99-UNK 15- NOWN 9 76•TOP 3 ,Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s iL 6 i.r.4 COM VEH 0 g! 1 C)
~ East Dundee I L 6011$ 0 1 0 FIRST CONTACT 5 7_: _O •Irves.See Sidebar U1 0
Z 8PHL115 CA 2026 REAR
TELEPHONE
IL D 0 KN DJ P3A5XJ7581737 Geico ❑Y ®N U2 m
B EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Rucker. Nyla. R. 6174732187 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER
RESPONDER
2 ou
N DRIVER ❑ PARKED ❑DRIVERLESS ❑ FED ❑PEOAL 0 EWES ❑NMV 0 NOV ❑DV
/1 9 6 6 Ford Ranger 2004 00-NONE O1 . 12.._, DUE TO CRASH ❑ 2 x
.. Yr 13-UNDER CARRIAGE 10� 2 FIRE ❑ ® U2 C
c
M 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X
❑Y NJ N ❑UNK VEH. AT CRASH 99-UNKNOWN `Oistract Dn Value 9 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s .i�..__4 COM VEH D ® U1 W
FIRST CONTACT 11 7 _,r_5 C.
If Yes.See Sidebar C
Z Carpentersville IL 60110 0 1 0 3839909B IL 2025 RFaR 0 Si)
D
IL D 0 1 FTYR14U04PA08334 American Property&Casua ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same PAIL00011470 BAc E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER
U1 =
(UNIT) (SEAT) (DOB1 (SEX) (SAFT) (AIR) (WI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)/(ADDRESS)/(TELEPHONE) (EMS) (HOSPITAL)
1 3 07 / F 2 4 0 1 0
m
/ / ##OCCS >
/ / UI 2 D
/ / 1 0
E/ MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
u 1 ® 11 1 8/ ,8/ /025 03 45 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 2
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 C)
2 ❑ 28 18
N 3 ❑ CITATIONS ISSUED 0 PENDING + / 0 PM• El Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 2
-a, ARREST NAME / / ID PM '
1 ® 1 1 1 UtilitySLMT
o NSECTION CITATION NO. ROAD CLEARANCE TIME El
0CITATIONS ISSUED PENDING
r 2 El ARREST NAME 8/ /8/ /025 03 45 ®PM ❑Unknown work zone type U1 30 El AM
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ 1542-Chase. Ethan 301 - / / ❑❑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 truckrtrailer -<
c ` --I -' r INDICATE NORTH combination):or -IBY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C1///
/ _ } (example:shuttle or charter bus):or 0
3. Is`""A""i I I 0 } } } transporting mployeened to slIn he courses or fewer o their em ynd ment example:employeerier Xtransporter-usually a van type vehicle or passenger car):or wC
i. `" __"' ot To Scale I •4. Is used or desi nated to trans rt between 9 and 15 ssen rs,including the driver, wi. I / } } } for direct compensation(examp large van used for specific purpose):or
.D< `-----i`----' / l. I t 5. Is any vehicle used to transport an hazardous material(HAZMAT)that requires
y mplacarding(example:placards will be displayed on the vehicle). XI
0D
'� CARRIER NAME Z/ 0
ADDRESS
/ .wry D
r r T 1 7 i. i. i. i. 4.
CITY/STATE/ZIP 0
/ - MOTOR CARR.ID 0 Interstate El Intrastate
❑ Not in Comm./Govt. 0 Not in Comm./Other
� "Y""1 USDOT NO. ILCC NO. m
XI
Source of above z
. Form Number
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' -n
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 o
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
Silver 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: 2 TOWED BY/TO.
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE