HomeMy WebLinkAbout2025-00053809 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003931251
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ®5501-$1.500 0 ON SCENE 7
VEHICLE/PROPERTY ❑OVER$1,500
®NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and f or Tow Due To Crash YR 202512025-00053809 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m
1660 LARKIN AVE El In 01:00
® ❑ RELATED ❑Y ®N 08 17 2025 ❑AM ❑YES ®NO U1
_ g PRIVATE mo !day!yr ®PM FLOW CONDITION m
COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR ❑SLOW 1 cn
❑ FT/MI N E S W Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
❑ 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 NW 0 NCV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
/ / FOR DAMAGEDAREA(S) FRO f TOWED U1 0
Unknown.O. Unknown Unknown 00-NONE „ 12 , DUE TO CRASH ❑
NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE 161 !!. 2 FIRE 0 M <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ❑ 0 U2 m
SYSTEM IN ENGAGED 15-OTHER 9 16.TOP 3
9 9 ❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `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
0 9 FIRST CONTACT 99 7_; _5 *Ilves.See&debar U1
Z UNKNOWN ' E
M TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1 11/
unknown ❑Y ❑N U2 I-
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Same unknown 1 rn
`o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y El 99 0
m g DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uv 0 NDv 0 DV
/1 9 5 4 FROM TOWED
Yaris 2009 00-NONE O,' t2 "_, DUE TO CRASH ❑ 2 x
0 Yr 13-UNDER CARRIAGE 10 I E FIRE 0 El U2 C
c
F 2 4 ❑Y ElElSYSTEM IN ENGAGED 15-OTHER 9,16-TOP 3 O
N UNK VEH. AT CRASH 99-UNKNOWN `Oistraci n Value
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-it 6 11:, 4 COM VEH ❑ ® U1 W
FIRST CONTACT 11 7� , 5 •(ryes.See Sidebar
ELGIN IL 60123 0 1 9912953 IL 2026 RFJ 0
IL D JTDKT903X95254538 Bristol West ❑Y ®N RDEF 73
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 99 =
Same G01521227801 BAG $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER®N U1 =
KNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL)
1 0
E/ MOST EVNT LOG DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
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N 1 CO 11 5 08,18 /2025 10 00 ®❑pM in a Work Zone? NJ DIRP D
1 1 PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 1 C)
T
F., 2 0 30 2 / ( ❑PM ❑Construction X
Z3 0 ❑CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 5
-a, ARREST NAME / / El PM '
o N ® 11 5 0 CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME El Utility
SLMT
99
1 0AM
T ❑PM 0 Unknown work zone type U1
2ARREST NAME ( / ❑
n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ID ❑AM Workers present? ❑Y 99
540-Dykema.Tracy 602 - / / 0 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.
A CMV is defined asmotor vehicle used to transportand:
r ----,5-••--, ; any passengers or property
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1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -<
} i.-- -;-- --; } } } r -, , ; ; , ; ( INDICATE NORTH combination)or —I
71
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
} ' i 1 , } (example:shuttle or charter bus):or
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3. Is
. L.___A_. . ..._... . . transporting edmployeeslIn5 hecourseeo theire rsmployment exam pal
e:employeener 73} } }
transporter-usually a van type vehicle or passenger car):or co
< <.__-a-_-_, , < <--_-a-___� , , , , 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver,
Pe ( P 9 Pe or 0
L L___-a____.: L L L ...._-..:_____� t i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
placarding(example:placards will be displayed on the vehicle). m,Zj
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CARRIER NAME Z
ADDRESS 0
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CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate ❑ Intrastate
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other O
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?
❑ Yes II No ElUnknown A
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 VIM 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
Blue
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 BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE