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HomeMy WebLinkAbout2025-00057723 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 011011001 11001001010 IOU DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003945775 u, 1 U21 3 4 1 U1 7 U2 1 U, 1 1_12 1 U, 1 U2 1 1 11 U1 1 U211 *P 0119* INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ® q 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 202512025-00057723 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 16 mSHALES PKWY Elgin ® ❑ RELATED ❑Y ®N 09 02 2025 ❑AM ❑YES E)NO U1 PRIVATE mo /day/yr 05:08 ®PM FLOW CONDITION m _ 10(� COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR 0 SLOW 15 rA 000,MI O E S W Route 20 WITH VEHICLES INVLD 0 STOPPED U2 --I 0 AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) Cook HIT&RUN ❑V ® N PEDALCYCLIST®N ® FREE FLOW # LNS 0 18:DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!Cy 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 3 n FOR DAMAGEDAREA(S) FRONT TOWED U1 0rue Krueger.Zachary.C. 0 1 yr 13-UNDER CARRIAGE ©10,I I�. 2 FIRE ❑ STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED El U2 3 <<i1 M 2 4 SYTM❑Y OS NEDUNK VEH. 0 ATCRASHD 0 15-99-UUNKNOWN THER9 16•TOP 3 `Distraction Value ALGN = r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF iL 6 I, 4 COM VEH 0 Ea 5 0 ~ 60110 0 1 0 FIRST CONTACT 11 7_: __5 *II yes.See Sidebar U1 Z 213501TW IL 2025 REAR TELEPHONE IL A 7 3HAEU M M L9SL723921 Pioneer ❑Y ®N U2 nni in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m CERTIFIED AUTO REPAI CPP120462006 1 r `o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY.STATE,ZIP PHONE NUMBER RESPONDER 98 X m x DRIVER 0 PARKED 0 DRIVERLESS ❑ FED 0 PEDAL 0 EWES 0 NPAy 0 NOV 0 Dv 1 9 5 3 Hyundai Tucson 2015 00-NONE 1("j 12..-_1 DUE TO CRASH ❑ 2 73 o y Yr 13-UNDER CARRIAGE 10'I c. 2 FIRE 0 ® U2 C Ti M 2 4SYSTEM IN 0 ENGAGED 0 15-OTHER 9,16-TOP 3 X 0 Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *0istracl n Value 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8-.;, 6 I t,-4 COM VEH ❑ ® U1 CO FIRST CONTACT 5 7 _,SOS •If Yes,See Sidebar ELGIN IL 60120 0 1 0 DS13956 IL 2025 REAR 0 IL D 0 KM8JU3AG5FU013121 Progressive ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Same 988551041 BAc $ HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Refused RESPOND O N U1 = (UNIT) (SEAT) (DOBI (SEX) {SAFT) (AIR) (INJI (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME)((ADDRESS)((TELEPHONE) (EMS) (HOSPITAL) 2 3 08 / F 2 3 0 1 0 m / / #OCCS D 7) / / U1 1 D / / 2 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 El 11 1 09/02 ,2025 05 08 ®PM in a Work Zone? NJN 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 0 2 28 03 , , 0 PM 0 Construction * Z 3 0 El CITATIONS ISSUED ❑PENDING SECTION CITATION NO. EMS ARRIVED TIME 5 ❑AM 0 Maintenance U2 o1 ® 11 1 ARREST NAME Krueger.Zachary.C. 11-601 S1529-000487 , r El PM SLMT o N ❑CITATIONS ISSUED ❑PENDING SECTION CITATION NO. ROAD CLEARANCE TIME • 0 Utility ❑ 35 t 2 El ARREST NAME AM 7 1 r ❑PM 0 Unknown work zone type U1 n OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME 2 2 3 ° 1529-Audi red.Jonathan 302 391-Jacobucci 10 ,07,2025 09 00 D PM AM Workers present? ®N U2 35 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 .. .. , I A CMV is defined as any motor vehicle used to transport passengers or property and: Z r r• -, I 1. Has a weight rating more than 10,000 pounds(example:truck or truckrtrailer -< i- 1 combination):or —I } r ' / r INDICATE NORTH p1 a BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C , / of _ } (example:shuttle or charter bus):or 0 L m X � / ror m srsa0� / 3. Is designed to carry 15 or fewer passengers and operated by a contract carrier I O I- <.__-A-.-.� 1_ / - i. } } } transportingemployees In the course of their employment pbyment(example:employee _ transporter-usually a van type vehicle or passenger car):or L L.___a.._.1 `` a ...... t_ 4. Is used or designated to transport between 9 and 15 passengers,including the driver. N __ __ } } for direct compensation(examp large van used for specific purpose):or O L L--_..I... .I. 111,111111111110 _ t l I I 5. Is any vehicle used to transport any hazardous material(HAZMAT)that requires m s, _ placarding(example:placards will be displayed on the vehicle). D XI x —I _ CARRIER NAME Z // -- ADDRESS O / T. ® g / 0 / CITY/STATE/ZIP < / i. MOTOR CARR.ID 0 Interstate 0 Intrastate ` ❑ Not in Comm./Govt. Not in Comm./Other 00 ; _Y_ _-1 USDOT NO. ILCC NO. m 73 Source of above z . 0 Yes II No ❑ Unknown 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 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 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w White Silver u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT' 2 TOWED BY/TO: _ SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TODUE TO DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 2 TOWED BY/TO. DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE