HomeMy WebLinkAbout2025-00057936 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 Df 2 Sheets 01111101111 1011011001 0
DID II
DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X003945.99*
u, 1 U21 3 4 1 U116 U2 1 u, 1 u2 1 u, 1 U2 1 1 10 u1 3 U2 3 *P 0119
INVESTIGATING AGENCY DAMAGE TO ANY El 5500 OR LESS TYPE OF REPORT ® q No Injury 1 Drive Away
AGENCY CRASH REPORT NO. TRFW
Elgin Police Department ONE PERSON'S 1215501-$1.500 ®ON SCENE 2
VEHICLE/PROPERTY ❑OVER 51,500 El NOT ON SCENE(DESK REPORT)
El AMENDED ElB Injury and for Tow Due To Crash YR 202512025-00057936 VENT
ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n
® ❑ RELATED ®Y 0 N 09 03 2025 ❑AM ❑YES ®NO U1 —<
BOWES RD Elgin12:02
g PRIVATE mo /day/yr ®PM FLOW CONDITION m
FTlMI N E S W SHASTA DAISY DR COUNTY PROPERTY ❑Y ® N DOORING ❑y #OF MOTOR ❑SLOW 15
❑ Kane HIT&RUN ❑Y ® N WITH VEHICLESOT,
INVLD DO
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 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 2 C)
FOR DAMAGED AREA(S) FROPff TOWED U1 Q
NAME(LAST,FIRST,M) Wine. Bette.A. mo 0 9 ! !1 9 4 5 Chrysler 200 2015 00-NONE „_ O i_, ODE TO CRASH ❑ EN
13-UNDER CARRIAGE 10 i ' 2 FIRE 0 NI E
STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 2 m
F 2 SY4 ❑Y ®SNE❑UNK VEH. 0 AT CRAS IN H 0 15-OTHER
99-UNKNOWN 9 76•TOP 3 `Distraction Value ALGN 2
r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF 8,_iL 6 4 COM VEH 0 ZgJ 1 0
" �- ST CHARLES IL 60175 0 1 0 FIRST CONTACT 12 7 ; _5 *II Yes.See Sidebar U1
ZSRT983 IL 2025 ' E
TELEPHONE
IL D 0 1 C3CCCEG7FN547410 State Farm ❑Y Il N U2 13 . m
13 EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m
99 9 Same 0778440-SFP-13 1 r
`o HOSPITAL(TAKEN TO) INCIDENT IF'V' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER
RESPONDER XI
Refused ❑Y ® N 2 c
g DRIVER ❑ PARKED 0 DRIVERLESS ❑ FED CI PEDAL 0 EWES ❑ uv 0 NCv ❑Dv
!1 9 8 3 Kia Motors Corielluride 2024 00-NONE ,t-1 12..-_, DUE TO CRASH ❑ C 2
o — 13-UNDERCARRIAGE 10;1 2 FIRE ❑ ® U2 C
c
F 2 4 SYSTEM IN 0 ENGAGED 0 15-OTHER 9 16-TOP 3 X
❑Y ®N ❑UNK VEH. AT CRASH 99-UNKNOWN *Oistrac on Value U1 0
POINT OF 8 iI 4 COM VEH ❑ ® W
N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR - 5 1'_
FIRST CONTACT 6 Y__{_O ._5 •If Yes,See Sidebar
— Batavia IL 60510 0 1 0 ET14312 IL 2025 REAR 0 C
IL D 0 5XYP64GC8RG542135 Travelers ❑Y ®N RDEF ZI
EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 =
99 9 Same 616042561 203 1 BAc $
HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 <
Refused RESPONDER u1 =
(UNIT) (SEAT) (DOB) (SEX) {SAFT) (AIR) (INJ) (EJCT) (EPTH) PASSENGERS&WITNESS ONLY (NAME),(ADDRESS)!(TELEPHONE) (EMS) (HOSPITAL)
1 0
EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur ❑Y U2 Z
u 1 ® 11 1 09/03 l2025 12 02 ®PM in a Work Zone? ®N DIRP co
1 I PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME If YES check one below: 7
T PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP ❑AM U1 �
0
2 28 18 ) ! 0 PM• ❑Construction *
Z3 0 l�CITATIONS ISSUED PENDING SECTION CITATION NO. EMS ARRIVED TIME ❑AM ❑Maintenance U2 7
—a ARREST NAME Wine. Bette.A. 11-601-Ax 1548000112 / ! El PM
1 ® 1 1 1 ❑CITATIONS ISSUED ❑PENDING Utility
SLMT
,
o N SECTION CITATION NO. ROAD CLEARANCE TIME Ely
0 AM
T 2 0 ARREST NAME 09/03 ,2025 01 00 ®PM ElUnknown work zone type U1 30
2 2 3 ❑ OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 30
1548-Crandall. Matthew 800 10 ,06,2025 01 30 ®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 truckrtrailer -<
' }---.r----; INDICATE NORTH combination):or —I
p1
N BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C
i No!Togcolo 1 IL - (example:shuttle or charter bus):or 0
3. Is designed to}_ -- i ` } carry15 or fewer passengers and operated I a contract carrier O
--- ----
- } } transporting employee � �In the course of their employment(example:employee X
transporter-usually a van type vehicle or passenger car):or w
L L____a____J ue: - 4. Is used ordesi natedtotrans rtbetween9and15passengers,includingthedriver. C
I. I. } • for direct compensation(example:large van used for speific purose):or
L L____a____� — �Z I. I _ 5 Is vehcleusedtotransporthazardous material(HAZMAT)thatrequires D
\^ e- placarding(example:placards will be anyisplayed on the vehicle). XI
I zti I armiontint I 21.
-- '{
CARRIER NAME Z
11 I Q ADDRESS
w
I CITY/STATE/ZIP 0
g
- i. i. i. i. MOTOR CARR.ID 0 Interstate 0 Intrastate
1 I r 1 ❑ 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. XI
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 ❑ 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
11
TRAILER 1 ❑ ❑ 0 Z
TRAILER 2 ❑ 0 0 O
u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. w
White Black
u 1 TOWED TOTAL VEHICLE LENGTH ft. NO.OF AXLES_
DUE TO ❑ DISABLING DAMAGE ® NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/TO:
_ . SELECT CODES FROM THE BACK OF CRASH BOOKLET
U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 1 TOWED BY/T6
DUE TO ® VEHICLE CONFIG. CARGO BODY TYPE LOAD TYPE