HomeMy WebLinkAbout2025-00054132 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY XO03929928
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INVESTIGATING AGENCY DAMAGE TO ANY El$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑5501-51.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash
0 AMENDED YR 2025I 2025-00054132 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 rn
N STATE ST Elgin03:09
® ❑ RELATED 0 Y ®N 08 19 2025 12,— ❑YES ®NO U1
PRIVATE mo /day/yr ®PM FLOW CONDITION m
FT!MI N E S W 190 WB EXIT RAMP COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR NI SLOW 2 Cl)
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD 0 STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL 0 EWES ❑uuv ❑!Cy ❑Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 0
FOR DAMAGEDAREA(S) FROuf TOWED U1 0Sowers. Mia. B. 1 0 /
yr 13-UNDER CARRIAGE O iFIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 2 DISTRACTED 0 ga U2 0 m
F 2 SYTM IN ENGAGE4 ❑Y ®SNE❑UNK VEH. O ATCRASHD O 99-UNKNOWN 016 3 `Distraction Value ALGN =
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 6,_iL 6 4 COM VEH 0 Ea 1 0
~ ELGIN N I L 60123 0 1 0 FIRST CONTACT 1 O 7 ; _5 *Irves.See Sidebar U1
ZDG95994 IL 2026 REAR
TELEPHONE
IL D 3N 1 CN7AP2KL821693 Travelers ❑v Il N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Stryker Auto Rentals 1 R571635TXS25 1 r
"o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER
2 eu
m tg DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED ❑PEDAL ❑EWES ❑ 1Av 0 NCv ❑Dv
1 9 6 9 Ford F150 2017 00-NONE 11 112 ...I DUE FIRE ID
CRASH 0 ® U2 2 C
...
_ 13-UNDER CARRIAGE III
c
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16•TOPO7 * X
❑Y Ni N ❑UNK VEH. AT CRASH 99-UNKNOWN O Distraction Value 0
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-.;,• 6 �( 4 COM VEH ❑ ® U1 CO
FIRST CONTACT 2 7-'_, _5 •(ryes.See Sidebar
= ELGIN IL 60123 0 1 0 2532097B IL 2026REAR C
IL D 0 1 FTFW1 EG8HKD35916 Allstate ❑Y ®N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 X
65 9 Same 962478905 BAC
$
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER U1 =
KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 CD 11 1 08 r 19 r2025 03 09 ®PM AM in a Work Zone? NJN 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
o", T 5 n
2 0 2 99 ! ! ❑PM• 0 Construction X
R 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 5
- U2
a, ARREST NAME Sowers. Mia. B. 4-A 1515-50W / r ❑❑PM ❑Maintenance SLMT
U 1 ® 11 1 CITATIONS ISSUED 0PENDING TIME • ❑Utility
o NSECTION CITATION NO. ROAD CLEARANCE 0 AM 45
t 2 ElARREST NAME Sowers. Mia. B. 11-905 1515-730 r r pM 0 Unknown work zone type U1
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑qM Workers present? ❑Y 45
1515-BellEck.Stacy 501 10 !07,2025 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.
. 0
r ----r••--, , I I - ; 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__--; I ( ( combination):or -<
INDICATE NORTH
BY ARROW 2 Is used or designed to transport more than 15 C
g sp passengers including the driver
} I r r r (example:shuttle or charter bus):or C)
L A 1i] 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
t } } transporting employees In the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or
4. Is used ordesi natedtotrans rtbetween9and15 passengers,including C
} } } for direct compensation(example:large van used for cific ur mdudi the driver,
./ ' ' ' '
Pe ( P 9 Pe purpose):or
L L L L _ 5 Is any vehicle used to transport any hazardous material(HAZMAT)that requires
113
placarding(example:placards will be displayed on the vehicle). ,Zmt
CARRIER NAME Z
ADDRESS 0
T.
o
ICITY/STATE/ZIP g
norm scare -
MOTOR CARR.ID 0 Interstate El Intrastate
I I I I I ❑ Not in Comm./Govt. 0 Not in Comm./Other
Y
USDOT NO. ILCC NO. m
XI
Source of above z
. ❑ Yes 0 No 0 Unknown g
D
Did Carrier Safety Regulations MCS)violation contribute to the crash? A
❑ Yes No ❑ 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'; 0 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
Black Red
u 1 TOWED •
TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO:
Redmons . 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