HomeMy WebLinkAbout2025-00056079 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets Millill I011011001 I0fl
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INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S El$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER 51,500 El NOT ON SCENE(DESK REPORT) El Injury and/or Tow Due To Crash
El AMENDED
YR 2025I 2025-00056079 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 r1
S LIBERTY ST El In07:43
® ❑ RELATED ®Y 0 N 08 27 2025 ®AM ❑YES E)NO U1 —<
g PRIVATE mo !day/yr ❑PM FLOW CONDITION III
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FT!MI N E S W BARRETT ST COUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR 0 SLOW 15 t)
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ® STOPPED U2 —I
Igl AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
Qg3 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 NIAV 0!CV 0 DV DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
NAME(LAST,FIRST,M) mo
/1 9 8 8 Nissan Sentra 2014 00-NONE
13-UNDER CARRIAGE 11 •
1z! DUE TOCRASH ® ❑
FIRE ❑
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) 1U IE
O DISTRACTED 0 0 U2 2 M
M 2 4 0SYSTM Y IN NE El UNK VEH. 0 AT CRASH 0 15-99-UNKNOWN THER9 76•TOP�3 ,Distraction Value 9 ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s• iI s �I COM VEH 0 j$J 1 0
~ ELGIN N I L 60120 0 1 0 FIRST CONTACT 2 7_: -_5 *II Yes.See&debar U1
Z S642367 IL 2025 REAR
TELEPHONE
IL D 0 3N1 CN7AP2EL821875 Goosehead Insurance ❑Y Il N U2 m
in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same Z4941222 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ❑ N 2 XI
p; DRIVER ❑ PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 MAv 0 NCv 0 DV
'1 9 9 0 NT Jeep(after 1986,}eerty 2018 00-NONE 0. Qi•-0 DUE TO CRASH ❑ 2 x
o yr 13-UNDER CARRIAGE 10( 12 FIRE El ® U2 C
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F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X
❑Y i N DUNK VEH. AT CRASH 99-UNKNOWN *Distraction Value g g
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s-iI�1:,-4 COM VEH ❑ ® U1 co
FIRST CONTACT 12 7�_, .5 ••(ryes.See SidebarC
H E LG I N IL 60120 0 1 0 CR25741 IL 2026 RFJ 0
IL D 0 3C4NJDBB1JT192087 Falcon Insurance ❑Y ®N RDEF XI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 0100136511 BAG E
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (DOBi (SEX) {SAFT) (AIR) (WI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 3 01 / F 2 4 0 1 0
m
/ / #OCCS D
/ / UI 2 D
/ / 1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 11 4 08,27 /2025 07 43 ®❑AM
in a Work Zone? ®N DIRP co
1 I 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 ❑ 20 06 ! / ❑PM ❑Construction >F
Z 3 ❑ I!!I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 3
❑AM El Maintenance U2
—a, ARREST NAME Lents. Matthew. R. 11-708 W1543000232 / / ❑PM
1 ® 11 4 0 CITATIONS ISSUED PENDING utilitySLMT
o u SECTION CITATION NO. ROAD CLEARANCE TIME ❑
AM U1 30
t 2 El ARREST NAME 08/27 /2025 07 43 [0 PM ❑Unknown work zone type
n 7 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ID ❑AM Workers present? ❑Y 30
1543-Sturgeon. Kyle 300 - , / 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.
r ----r••--, , I I A CMV is defined as any motor vehicle used to transport passengers or property and: Z
--I-- I I @ 1 combination):or g ore than pound { a p .truck or truck trader.......je
1. Has a weight ratio m 10 000 5 ex m le� � -<
INDICATE NORTH p3
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
t- Not To Scale I - (example:shuttle or charter bus):or 0
3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
�- --I `
._ o.l. } } } transporting employees In the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
L L.__.a-___3 ar,.nv�w + e I. •4. Is used ordesi natedtotrans rtbetween9and15 ssen rs,induding[hedriver, O
1 _ I } } } for direct compensation(examp large van used for specific purpose):or
f I I l. i i _ 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle).
- CARRIER NAME Z
I — ADDRESS 'n
\ w
to
+;'/ ` I III' . CITY/STATE/ZIP
uumn I I I - MOTOR CARR.ID ❑ Interstate ❑ Intrastate
0
1 I 1 I ❑ Not in Comm./Govt. 0 Not in Comm./Other 0
Y
USDOT NO. ILCC NO. m
Source of above z
. • m
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
Black Black
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT- 3 TOWED BY/TO.
_Adieu/Impound Lot Garage . 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