HomeMy WebLinkAbout2025-00055328 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 4 Sheets 01111101111
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DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003945 63
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INVESTIGATING AGENCY DAMAGE TO ANY ❑5500 OR LESS TYPE OF REPORT El A No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S ❑5501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500 ❑NOT ON SCENE(DESK REPORT)
0 AMENDED ® B Injury and f or Tow Due To Crash YR 202512025-00055328 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 15 m
® ❑ RELATED 0 Y ®N 08 24 2025 ®AM ❑YES ®No u1 —<
N AIRLITE ST Elgin04:58
_ _ g PRIVATE mo /day/yr ❑PM FLOW CONDITION m
FT!MI N E S W FOOTHILL RD COUNTY PROPERTY ®Y ❑N DOORING ❑y #OF MOTOR 0 SLOW Cl)
❑ Kane HIT&RUN ❑V ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I
® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ® FREE FLOW # LNS 0
Q83 DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEoa. 0 MUSS 0 uuv 0 lacv 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 0
1 FOR DAMAGEDAREA(S) FROM TOWED U1 Q
NAME(LAST,FIRST,M) Bertolini, Robert. R. mo0 /
13-UNDER CARRIAGE 10 FIRE 0
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) O DISTRACTED ® 0 U2 m
M 2 4 SYTM❑Y ®SNE❑UNK VEH. 0 ATCRASHD 0 15-99-UUNKNOWN THER9 t6•TIDP 3 `Distraction Value 3 ALGN X.
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s_iL 6 ii,4 COM VEH I1 0 1 0
F. FIRST CONTACT 1 7_;—_;__5 *I(Yes.See Sidebar U1
Z Algonquin IL 60175 0 1 0 FD81899 IL REAR
TELEPHONE
IL D 0 1 FMSK$KH5NGB74922 none ❑Y ❑N U2 13 . m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same none 1 r
o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Refused ❑Y ® N 2 rg-
0 DRIVER 0 PARKED 0 DRIVERLESS 0 FED 0 PEDAL 0 EWES 0 NI/V 0 ICV 0 DV
yr 12 _ 71
o 13-UNDER CARRIAGE 10 I 2 FIRE ❑ ❑ U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP3 ❑ 0 SPDR 0
❑Y ❑N D UNK VEH. AT CRASH 99-UNKNOWN *Distraction Value U1 0 -
POINT OF s-.;, 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRSTO CONTACT Y 6 I._
CIOMs gee SidebarH
❑ C
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F` REAR` co
M . STATE CLASS CDL ID VIN INSURANCE CO. EXPIRED U2 O
❑Y ❑N RDEF
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
BAC
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 997 <
RESP❑YD❑N NDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) 0
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E/ MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 El 43 3 08,24 ,2025 04 58 ®❑pM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 3
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ®AM U1
✓ t 2 ❑ 08 99 08,24 ,2025 05 24 ❑PM El Construction
<ov 3 0 ]$I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME
z J ®AM ❑Maintenance U2
—a,
oARREST NAME Bertolini, Robert, R. 12-610.2-B 747796 08,24,2025 05 29 ❑PM SLMT
u 1 0 B!CITATIONS ISSUED 0 PENDING SECTION CITATION NO. ROAD CLEARANCE TIME AM El Utility
t 2 El ARREST NAME Bertolini, Robert, R. 11-601-Ax 747795 08,24 ,2025 05 35 [M PM 0 Unknown work zone type U1 35
CO 2 3 0
OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ®AM Workers present? ❑Y
1544-Solis,Yulissa 602 331-Ziegler 09 /25,2025 09 00 ❑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 A CMV is defined as any motor vehicle used to transport passengers or property and: Z
N 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -<
c ` -'- ' r INDICATE NORTH combination):or —I
BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
"10"8° } (example:shuttle or charter bus):or 0
X
Li 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O
- } } } transporting employees in the course of their employment(example:employee X
' transporter-usually a van type vehicle or passenger car):or w
4. Is used ordesi natedtotrans transport passengers,including C
} } } g po passen rs,includi the driver,
I I _ I for direct compensation(example:large van used for specific purpose):or O
.Aw.
ist
II
' — —— —/ l. i i 5. Is any vehicle used to transport an hazardous material(HAZMAT)that requires m
placarding(example:placards will be displayed on the vehicle).
.../ ` CARRIER NAME Z
'MW e _ - __ ADDRESS O
1 [ . . . . 1.
CITY/STATE/ZIP I 0
_ MOTOR CARR.ID Interstate Intrastate
' Not To Scale l i 0 Not in Comm./Govt. 0 Not in Comm./Other 0
�I. ------1 USDOT NO. ILCC NO. C
m
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 ® 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 ®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_COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
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_DUE ETOO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/TO:DUE T VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE