HomeMy WebLinkAbout2025-00057694 (2) ILLINOIS TRAFFIC CRASH REPORT Sheet 3 of 4 Sheets HUI III 11 111111
DRAG TRFD TRFC WEAT DRVA VIS VEHD LGHT COLL MANV
u, 1 U2 1 1 1 U, 1 U2 U, 1 U2 U, 1 U2 1 11 U1 11 U2 *P 0119*
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 El$501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and f or Tow Due To Crash
El AMENDED
yR 202512025-00057694 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 3 -n
S MCLEAN BLVD El In03:34
® ❑ RELATED ❑Y ®N 09 02 2025 ❑AM ❑YES ®NO U1 -<
g PRIVATE mo !day/yr ®PM FLOW CONDITION m
®!MI N E s w College Green Dr COUNTY PROPERTY 0 Y ® N DOORING ❑y #OF MOTOR ❑SLOW Cl)
g Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ® STOPPED U2 --I
❑ AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N ❑ FREE FLOW # LNS 0
(g)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 5 C)
0 7 !
yr
Jacks.William.J. Ford Transit Connect 2013 00-NONE ,, -
•, DUE TOCRASH ® ❑
Q
13-UNDER CARRIAGE 10 i 2 FIRE 0 IE C
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 m
M 2 SY is-OTHER
4 ❑Y ®SNE DUNK VEH. O AT CRASH M IN O O 99-UNKNOWN 9 16•TOP 3 ,Distraction Value 9 ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF iII s ti_4 COM VEH ❑ �! 1 C)
~ ELGIN I N I L 60123 B 1 0 FIRST CONTACT 6 O::L:Q_O =II Yes.See Sidebar U1 0
Z 3705151B IL 2025 REAR
TELEPHONE
IL D 0 NMOLS7CN3DT159684 State Farm ❑v ®N U2 m
5 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
Elgin Fire 99 9 Same 3701828SFP13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF`Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER D
Provena St.Joseph ❑Y ® N 2 0
❑ DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 row 0 Ncv 0 DV
yr 12 _ C1
o 13-UNDER CARRIAGE 10 I c. 2 FIRE 0 ❑ U2 C
c SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED
a SYSTEM IN ENGAGED 15-OTHER 9,16-TOP 3 ❑ 0 SPDR O
❑Y ❑N ❑UNK VEH. AT CRASH 99-UNKNOWN `Distraction Value U1 0 -
POINT OF &-.;, 4
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR FIRST CONTACT Y�=1-.:-5 COM•I sVEH See •Sidebar❑ 0
C
CO
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 996 <
RESP❑YD❑N NDER U1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)!(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL) n
/ / U2 r
m
/ / ##occs >
Pj
/
0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
N 1 ® 11 1 91 ,12 !25 03 34 ®pm in a Work Zone? ®N DIRP co
T 2 0
PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 1 0
1 t L 9J !J2 !25 03 34 ®PM ❑Construction >F
Z3 ❑ 0 CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2
-a, ARREST NAME 9) ,12 !25 03 37 ®pM '
o u 1 ❑ ❑CITATIONS ISSUED ❑PENDING UtilitySLMT
o N SECTION CITATION NO. ROAD CLEARANCE TIME ❑
0 AM
r 2 ❑ ARREST NAME 9) !)2 125 04 20 0 PM ❑Unknown work zone type U1 35
n T OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 3 0 1563-Rodriguez.Carlos 702 391-Jacobucci 10 ,21 ,2025 01 30 ❑❑pM Workers present? ®y
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 A CMV is defined as for vehxae used to tra and:
r ----,5-••--, ; any mo nsport passengers or property
Z
1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -
} }-- -;-- --; } } } r -, , ; ; , ; ( combination):or —I
INDICATE NORTH 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
x
3. Is
L L.___A.. 1 i. <--_- - J transporting edmployeeslIn5 hecourseeo theire rsmployment exam pal
e:employeener 73} } }
• � . transporter-usually a van type vehicle or passenger car):or co
< <.__-a-_-_, , < .---_-a-___� , J. , , 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____.I L L L ...._-..i._ 1 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). XI
--I
CARRIER NAME Z
i.
ADDRESS 0
fh
CITY/STATE/ZIP
MOTOR CARR.ID 0 Interstate 0 Intrastate
0
❑ Not in Comm./Govt. ❑ Not in Comm./Other 0
USDOT NO. ILCC NO. m
XI
Source of above z
) ❑ Side of Truck [0 Papers 0Driver ❑ Log Book m
Z
GVWR/GCWR 1
El <10,000 0 10,000-26,000 0 >26,000 z
Were HAZMAT placards on vehicle? 0 Yes 0 No =
If Yes,Name on placard O
4 digit UN NO. 1 digit Hazard class No.
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? 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
73
IDOT PERMIT NO. WIDELOAD-; ❑Yes 0 No 2
TRAILER VIN 1 m
to
LOCAL USE ONLY TRAILER VIN 2 m
v
TRAILER WIDTH(S) 0-96" 97-102" >102' T
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 3 COLOR U_COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z
Blue,Dark
U 3 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO.
_Mies/Impound Lot Garage SELECT CODES FROM THE BACK OF CRASH BOOKLET
U_TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: TOWED BY/T6
DUE TO VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE