HomeMy WebLinkAbout2025-00056520 ILLINOIS TRAFFIC CRASH REPORT sheet 1 of 2 Sheets 01111101111 011011001 11011111111111
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X00393461
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INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW '
DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT ® A No Injury 1 Drive Away
Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 1
VEHICLE/PROPERTY ®OVER$1,500
❑NOT ON SCENE(DESK REPORT)
0 AMENDED ❑ B Injury and/or Tow Due To Crash YR 202512025-00056520 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 99 m
1400 LONGFORD CIR Elgin08:09
® ❑ RELATED 0 Y ®N 08 28 2025 ❑AM ❑YES El NO U1
_ g PRIVATE mo /day/yr ®PM FLOW CONDITION m
COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 1 (n
❑ FT!MI N E S W Cook HIT ®Y ❑ N WITH VEHICLES INVLD 0 STOPPED U2 --I
El AT RUN AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER I] PARKED 0 DRIVERLESS 0 PED ❑PEDAL 0 EWES 0 NW 0!CV 0 ov DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0
/ / FOR DAMAGEDAREA(S) FROftf TOWED U1 0
Unknown.0. Unknown Unknown 00-NONE 11,• 12 DUE TOCRASH ❑
NAME(LAST,FIRST,M) mo yr 13-UNDER CARRIAGE I !�. 2 O FIRE 0 IE
10 <
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED ® 0 U2 m
F 9 9 ❑Y SYSTEM IN ENGAGED 15-OTHER 916.TOP
�3 _
❑N ❑UNK VEH. AT CRASH 99-UNKNOWN Distraction Value 9 ALGN
S O
T. CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF i� 6 �I COM VEH ❑ Ea 1 0
F_ 0 9 FIRST CONTACT 1 7 _L-_;_( •If Yes.See&debar U1 0
c REAR
Z
E
TELEPHONE . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED 1
Unknown ❑Y ❑N U2 I—
in 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
0 DRIVER X. PARKED 0 DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 m/v 0 NOV 0 Dv
yr Ford Fusion 2011 00-NONE „ 12 _, DUE TO CRASH ❑ ® 1 a7
Ti 13-UNDER CARRIAGE FIRE ❑ El U2 C
SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O 2 DISTRACTED
a SYSTEM IN 0 ENGAGED 0 15-OTHER 016-TOP 3 ❑ ® SPDR 0
❑Y ®N DUNK VEH. AT CRASH 99-UNKNOWN `Oistracton Value 0 -
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF O I _ I. 4 COM VEH ❑ ® U1 CO
FIRST CONTACT 7 Qi .s •If Yes.See Sidebar C
EQ15927 IL 2025 REAR
O N
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 0
3FAHPOJG8BR338717 Geico ❑Y ®N RDEF X
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 2006-48-47-09 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
ERESPONDER
E U1 =
Y
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)1(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z
N 1 ® 18 9 08,28 /2025 08 09 ®AM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 1
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1
2 ❑ 20 99
N 3 ❑ CITATIONS ISSUED 0 PENDING + / ❑PM• El Construction
SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 1
z
-a, ARREST NAME / / El PM
o N 1 ® 11 1 0 •
CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ❑Utility SLMT
t 2 ❑ 25
AM
T / / ❑❑PM ❑Unknown work zone type U1
ARREST NAME
nlx- OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME
2 2 3 ❑ - ❑AM Workers present? 0 Y 25
455 Halla�.Gabriel 302 , / 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••--, , ; 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 -<
` ` ' ' I. INDICATE NORTH combination):or
unm2 i BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver n
_ (example:shuttle or charter bus):or
>- 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
I- <____A____J --iI _ }} } transporting employees in the course of their employment(example:employee X
�t--I_. transporter-usually a van type vehicle or passenger car):or co- } } } 4. Is used or designated to transport between 9 and 15 passengers,including the driver. (I)for direct compensation(example:large van used for specific purpose):or 0
0 INII
L L____a____. r,-•,i i. i i t 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires
t' ,t placarding(example:placards will be displayed on the vehicle). XI
Alli In
�'r�+ CARRIER NAME
Urdt?t ~�~ _Glow:
i ,... r
111f _ __ ADDRESS
Not To Scale 1
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
If Yes,Name on placard 0
4 digit UN NO. 1 digit Hazard class No. Xl
Xl
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
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 ❑ O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Silver
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/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE